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SAN JOAQUIN LOCAL. HEALTHDISTRICT S� <br /> FO OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. 4. 0,6mm-Der <br /> Telephone: (209) 466-6781 1fS9� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Np. <br /> THIS' PERMIT MIRES 1 YEAR FROM DATE ISSUED Date Issued 4E-t <br /> F (Complete In Triplicate) <br /> Application 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 /> and Regulations of the San Joaquin Local Health Diatrict, <br /> County Ordinance No. 1862 and the Rules <br /> JOB ADDRESS/LOCATION � S,- — CENSUS TRACT <br /> F Phone . <br /> Owner's Name U - <br /> Address �� r city <br /> �- <br /> G c Ip <br /> License Phonefq Z-�-W <br /> Contractor's NameISO <br /> .� frZs <br /> i <br /> TYPE OF WORK (Check) : NEW WELL /� DEEPEN /� RECONDITION /_7 DESTRUCTION f_7 <br /> PUMP IN-STLATION / / PUMP REPAIR/� PUMP REPLACEMENT I_ T <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES /, j PIT PRIVY <br /> SEWAGE DISPOSAL FIELD C SSPOOL/SEEPAGE PIT OTHER `4 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELLalasa <br /> INTENDED USE TYPE,,OF WELL CONSTRUCTION SPECIFICATIONSA. kA' <br /> Industrial <br /> Cable Tool Dia. of Well Excavation 2v <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of-'Casing- -- ._ +�`� b4 <br /> Irrigation Gravel Pack Depth of Grout Seal , <br /> Cathodic Protection Rotary ,.�. T}rpe� of 'Grout _ <br /> Disposal. Other Other Information � <br /> Geophysical Surface Seal Instal ed B : ? / <br /> �. .• A <br /> PUMP INSTALLATION: Contractor 1 <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Doner , <br /> r PUMP .REPAIR: / / State Work Done z <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the Sax, Joaquin Local Health District <br /> and the State of California pertaining to or regulating well 'construction. Within FIFTEEN DAYS <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 the well 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 CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FI AL INSPECTION. TITLE / <br /> ' SIGNED Ole Co <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> OR DEPARTMENT USE ONLY . <br /> PHASE I DATE <br /> APPLICATION ACCEPTED--BY-3 <br /> ADDITIONAL COMMENTS: P S /FIN I PECTION <br /> PHASE II GROUT INSPECTION INSPECTION B DAT7 <br /> INSPECTION BY DATE 6 7 E <br />