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M SAN JOAQUIN LOCAL HEALTH DISTRICT y <br /> FOE:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466.6781 <br /> f <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Sy3tc <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> I (Complete In Triplicate) <br /> Application io hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquix <br /> k County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> F <br /> JOB ADDRESS/LOCATION <br /> { CENSUS TRACT <br /> Owner's" Name P . <br /> hone R9 7 3 S`Z <br /> Address /P . <br /> City.. . <br /> Contractor's Name <br /> License Phone <br /> TYPE OF WORK (Check) : NEW WELL/-T DEEPEN '/-7 RECONDITION /-_f DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR/? PUMP REPLACEMENT J f <br /> Other / / -- <br /> E�.� <br /> { .DISTANCE TO NEAREST: SEPTIC TANK ':! ,..SEWER LINES FIT PRIVY <br /> � SEWAGE DISPOSAL FIELD` S CESSPOOL/SEEPAGE FIT OTHER - <br /> PROPERTY LINE PRIVATE.DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRilCTION SPECIFICATIONS. <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled, .. ., Dia. of Well Casing <br /> IrrigatioDomestic/n <br /> Driven Gauge of Casing <br /> Irrigation ' � 'k `. Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary �r Type of Grout <br /> Disposal Other Other--Informationi' <br /> Geophysical Surface Seal Installed 'B <br /> PUMP INSTALLATION: Contractor <br /> i Type -of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done - <br /> PUMP '.REPAIR: . /_7 State Work_Done <br /> DESiTRUCTION OF WELL:. Well Diameter <br /> Desc ib Ma eria and Procations edu 91 ApproximatDeth <br /> �m c <br /> I hereby agree to comply with ali haws and regulhof the San Joaquin Local Healt District <br /> And the State of California pertaining to or regulating well "construction. Within FIFTEEN DAYS <br /> after completion of 4thb;s <br /> a new well, I will furnish the .San Joaquin Local Health District-a <br /> WELL DRILLERS REPO ll and notify them before <br /> information t u t a'f my knowledge and belieftting-the.-well in use... The above <br /> l WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G N' <br /> SIGNED <br /> ON. , <br /> TITLE,' <br /> - - (DRAW PLOT PLAN-ON"REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> AP''LICATION ACCEPTED BY <br /> ADDITIONAL CUMMENTSt . <br /> -DATE <br /> DATE U la <br /> PHASE II GROUT INSPECTION <br /> INSPECTION -BY PHA IIF NAL INSPECTION <br /> DATE INSPECTION BY DATE I <br /> E H 1426 �j/���-.. ����•� C � �y I <br />.4` Rev. 1-14 J"" <br />