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FO1SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> -----i- <br /> Telephone : X (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 Sf�`r' �� <br /> (Complete In Triplicate) .Application �------ <br /> is 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 Joaquin <br /> :. County Ordinance o S62 .and the esu d attian of�e/ an Joaquin Local Health :District. <br /> � <br /> JADDRESS/LOCATION QCPA <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Ad d r e s s <br /> City 3 . <br /> Contractor's Name <br /> i License X j�W Phone` j <br /> TYPE OF WORK k) <br /> (Chec : NEW WELL <br /> i /2�7 'DEEPEN I I RECONDI'T'ION /_/ DESTRUCTION / <br /> / <br /> PUMP INSTALLATION `PUMP REPAIR <br /> Other / / PUMP REPLACEMENT / N <br /> f DISTANCE TO NEAREST: SEPTIC TANK Z <br /> .SEWER LINES PIT PRIVY <br /> } SEWAGE DISPOSAL FIELD - CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIOT <br /> HER <br /> INTENDED USE WELL OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well. Excavation / <br /> �mestic/private Drilled <br /> Domestic Dia. of Well Casing rim <br /> /public Driven Gauge of Casing <br /> 07 <br /> Irrigation Gravel Pack Depth, oft Grout Seal <br /> Cathodic Protection t�atary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical ------- <br /> Surface Seal#'Install--e..d_T3_ <br /> PUMP INSTALLATION: Contractor 4 <br /> Type of Pump <br /> P. <br /> PUMP REPLACEMENT; n -�" -�.� . . x,,. ....�.� ., <br /> H. '- _ <br /> State�Wozk Done j <br /> PUMP .REPAIR: € * N.� 1-4 <br /> State Work Done <br /> DES-TRUCTION OF WELL: f Well Diameter. -_ - L � <br /> # ; 47 _,.w - �*r ^-� _ Approximate Depth ¢ <br /> Describe Material and Proced�ur'e" <br /> I hereby agree to comply with all lawsk nd regulations of the San Joa uin Loca E' <br /> and the State of California •pertaining to or regulating well construction. WithinaFIFTEENtDAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District •a <br /> WELL DRILLERS-REPORT of thepwell and notify them before putting the well in use.... The above <br /> information is true to the best of- my knowledge and belief., I WILL GALL FOR A GROUT INSPECT <br />'RIOR TO GRO TIN , AND A .FINAL INSPECT ON. ON <br /> SIGNED <br /> `TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) . <br />,MASE I FOR DEPARTMENT USE ONLY <br /> FPPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: f DATE �2 �� <br /> PHASE IIi ROUT' ECTTON <br />:NSPECTION BY DATEiPHASE III/FINAL INSPECTION -AGF-- <br /> '��j 'INSPECTION,-s BYk <br /> DATE �.Zp <br /> S-2401 <br /> .E -H 1426 <br /> 4 . <br />