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� SAN JpAgUIN LOCAL HEALTH DISTRICT <br /> - <br /> IN <br /> tockton, Calif. ;7;7 <br /> _ <br /> �nR OFFICE USE. 1601 E. Hazelton Ave. ,A{20 ) 466-6781 <br /> Telephone: PERMIT Permit No. <br /> APPLICATION FOR WELL CONSTRUCTION OR Date Issued3r � <br /> THIS PERMIT EXPIRES d <br /> (CompleteiFROM <br /> is te)E ISSUED permit-to construct <br /> fiance with San Joaquin <br /> application <br /> Applic <br /> anon is hereby made to the San Joaquin Local <br /> isDist <br /> made in conPLocal Health District. <br /> 1862 and the Rules and Regulatio <br /> County Ordinance Nons of the San Joaquin <br /> and/or instul�. the work herein described. This . <br /> . ` CENSUS TRACT <br /> JOB ADDRESS/LOCATION Gi <br /> Phone <br /> Owner's Name V City <br /> Address , ) ' License #', Q.kThone <br /> Contractor's Name <br /> ' fDESTRUCTION /? <br /> EW WELL _�D�EEPEjj.47F-RECONDITION /7 REPLACEMENTTYPE OF WORK (Check): NpUME REPAIR /� <br /> PUMP INSTALLATION / 11 Z� <br /> other 1 1 <br /> ; SEWER LINES _PIT PRIVY \ <br /> DISTANCE TO NEAREST: SEPTIC TANK CESSPOOL/SEEPAGE PIT �� _ OTHER <br /> SEWAGE DISPOSAL FIELD PUBLIC DOMESTIC WELL <br /> PROPERTY LINE _ PRIVATE DOMESTIC WELL CONSTRUCTION SPECIFICATIONS \ <br /> INTENDED USE TYPE OF LL <br /> Cable`.Tool Dia. of Well Excavation F, <br /> Industrial :.._ - Dia. of .Well Casing <br /> I . Domestic/private _ Drilled of Casing <br /> 1'.-Driven Gauge <br /> t mestic/public,. Gravel Pack Depth of Grout Seal <br /> f Irrigation a of Grout , <br /> F . Cathodic Prdtec,ti.nn .,Rotary . Type <br /> _A /Other Other Information' ' <br /> _ Disposal z: -� .�- Surface`Sea1 Installed 'B <br /> Geophysical - <br /> 4�- <br /> PUMP INSTALLATION S. Contractor? 1(7 H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: - / f/ State Work Done , <br /> PM ,REPAIR: / tate Work Done <br /> i Approximate Depth <br /> DESTRUCTION OF WELL: : Well Diameter <br /> Describe Material and Procedure <br /> I hereby agree to comply, with all laws and regulations of the San Joaquin Local Health District <br /> construction. Within FIFTEEN DAYS <br /> and the State of Californipertaining to or regulating well <br /> a <br /> after completion of my work on anew well, Ithemlbeforesputtingh the athe�well. i use-.HeTheh above <br /> WELL DRILLERS REPORT of the well and notify <br /> information is true to the-best of my knowledge and belief. I WILL CALL -FOR A GROUT INSPECTION <br /> PRIOR TO GRO N AN A INS CTiON. TITLE e. <br /> kSIGNED (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> I <br /> PHASE I DATE ' 3 Z'3 I <br /> n <br /> `.-APPLICATION ACCEPTED BY V� <br /> ADDITIONAL COMMENTS: PHASE ]CII FINAL INSPECTION <br /> PHASE II GRO11 Ull T INSPECTION INSPECTION BY <br /> INSPECTION BY DATE .. <br />