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SAN JOAQUIN LOCAL Ii1�ALTH DISTRICT <br /> 0 5 IV <br /> i, FOH OFFICE USE: <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 Permit No. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT �Q <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) permit to construct <br /> Application is hereby made to the San .Joaquin Local Health District for a p <br /> in described. This applrestof hSanJoaquinLocalHealth <br /> application is <br /> ecompliance <br /> San <br /> Distric <br /> uin <br /> and/or install the work heret. <br /> County Ordinance No. 1862 and the Rules and Regulation <br /> +� ®Q d4 CENSUS TRACT <br /> JOB ADDRESS/LOCATION �C f7 CJ _ <br /> n Phone <br /> Owner's Name <br /> City ../ <br /> Address <br /> �r r <br /> License #0?- ow Phone <br /> Contractor's Name' -- <br /> _- <br /> t PE OF WORK (Check) : NEW WELL // DEEPEN / f �RECONDITION /_/ DESTRUCTION T <br /> TY EpUMP 1t PAIR / f PUMP REPLACEMENT I7.._. <br /> PUMP INSVALLATION- ' s <br /> Other <br /> SEWER-LINES.—.. .PIT PRIVY '. <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER <br /> SEWAGE DISPOSAL FIELD ,F,���GESSPOOL/SEEPAGE PIT � <br /> '-`-"PUBLIC DOMESTIC WELL <br /> PROPERTY LINE - PRIVATE]30MFS.TICWETLCONSTRUCTION SPECIFICATIONS c <br /> INTENDED USE TYPE OF WELL <br /> Cable Tool Dia, of° Well Excavation <br /> industrial , � �� �� <br /> Dia, ,of. Well Casing <br /> Drilled _; <br /> . Domtstic/prvate } <br /> J_D�dme s.t i c/-pub l i s <br /> ),�3 0°• Dyvv.en) Gauge of 'Casing <br /> ! , ,-Irrigation - s Graver Pack Depth of Grout Seali <br /> *� <br /> X. ,� �;4 -w Te of Grout <br /> Cathodsic Protection Rotary Other Information <br /> Disposal Other --____,� <br /> l Surface Seal Installe <br /> —Geophysical <br /> d 'B <br /> PUMP INSTALLATION: Contractor ! H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> "- State Work DoneF <br /> PUMP .REPAIR: I / 7 <br /> ppro�;imate Depth 1 _� <br /> DESTRUCTION OF WELL: Well Diamettery yr <br /> Describe Material and Procedure <br /> a ree to comply with all laws and regulations of the San n <br /> Jaaqui �=Local Health District <br /> hereby' I y g <br /> and the State of California pertaining to or regulating well'construction: Within FIFTEEN DAY <br /> after completion of my work on a new well, I will furnish the San JoaquinLocal Health District <br /> WELL DRILLERS REPORT of the well and notify them before putting ldlL e - CALL FOR Ae... The <br /> eUT INbovCTION <br /> information is true to the best of my knowledge and belief. <br /> I PR10R TO GRO ING AND A INA INSPECTION. TITLE <br /> SIGNED (DRAW PLOT PLAN ON REVERSE SIDxi <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE Ill <br /> APPLICATION ACCEPTED BY <br /> 4 ADDITIONAL COMMENTS: _ PHASE I/FI AL INSPECTION <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY <br /> INSPECTION BY DATE Al�V (�G j <br /> 2M <br />