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A 4 ' <br /> ki A ' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> FO£� OFFICE USE: Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _ <br /> . - THIS PERMIT EXPIRES' 1 -YEAR FROM DATE ISSUED <br /> Date 'issued 7;tl— <br /> (Complete In Triplicate) <br /> Application is hereby made to the Son Joaquin Loc <br /> osallicatian istmade inrcnmpliancea permittwith SanconstruJoaquin! <br /> .and/or install the work herein described. pp <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> F P/ V/j CENSUS TRACT <br /> JOB ADDRESS/LOCATION U c � <br /> Phone <br /> Owner's Name A, p <br /> city ,711 <br />�. Address <br /> ' r License,# �: Phone <br /> Contractor's Name4 - ; <br /> t E WELL ,/� DEEPEN '/� RECONDITION /_� DESTRUCTION <br /> TYPE OF WORK (Check): — PUMP REPAIR I� PUMP REPLACEMEN?7 <br /> \ PUMP INSTALLATION /,.� ; <br /> ��. � � �ther I I1 � �,i � . . _ . <br /> ` IT PRIVY <br /> DISTANCE TO.,NEAREST-: SEPTIC TANK ; 'SEWER LINES,, <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ° PUBLIC DOMESTIC WELL <br /> *\44" PROPERTY LINE - PRIVATE DOMESTIC WELL <br /> INTENDED USE TYPE OI' WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial <br /> Cable Tool. Dia. of Well Excavation <br /> Drilled Dia. of Well Casing <br /> Domestic/,private ----- Driven Gauge of Casing <br /> Domestic/public � . . � � <br /> Irrigation: Gravel Pack" Dep.th.of Grout Seal <br /> F Rotar Type of 3 Girout <br /> Cathodic <br /> protection y Other Information <br /> ► Disposal Other i . . . <br /> Geophysical Surface,Seal'Installed•'B <br /> PUMP INSTALLATION: Contractor <br /> n. Type of Pump <br /> k <br /> 11 <br /> PUMPREPLACEMENT'' / /. State Work Dose 1,1 <br /> � . <br /> PUMP '.REPAIR: A\ <br /> S/ State Work Done ' / <br /> 4 F WEAL: Well Diameter ;- -' Approximate Depth <br /> DES•TRUCTIflN O <br /> F Describe Material,-and Procedure id*`r�� / �'`���"`� <br /> = w v 7' s <br /> ltb <br /> rict <br /> T I hereby Xagree " o comply with all--laws and regulations °well construction.L�WithinaFIFTEENCDAYS <br /> ' and the/State o California pertaining to or regulating <br /> after eampletio of my work on a new well,, I will furnish the San Joaquin LocalfRealth.District a <br /> WELL DRILLERS REPORT of the well and notify them before putting_ the .well. in-.use`... .The above <br /> j-'" ' ter—� ILL-CALIrFOR 'A GROUT INSPECTION <br /> information is true to the-best of my knowledge and belief. <br /> PRIOR TO GROUT.�NG"AND._A. 'INAI;IIdSPEION. <br /> SIGNED 1 #`�"" .:f:TITLE <br /> .. {'DRAW PLOT PLAN-ON REVERSE SIDE <br /> FO EPARTMENT USE ONLY <br /> PHASE 'I DATE `� 7S <br /> APPLICATION ACCEPTED BY <br /> AD DITIONAL_COMMELdTS "a`"` r <br /> PHAS �IIF AL INSPECTION <br /> 1 .PHASE 11 GROUT INSPECTION INSPECTION BY DATE <br /> INSPECTION BY DATE <br /> , .. stns r 7_71. <br />