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MICE <br /> SAN JOAQUIN LOCAL HEALTH DISTRICTf' 1601 E. Hazelton Ave. , •,Stockt 'on, Calif. <br /> t , Telephone: (209). 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> o.THIS PERMIT EXPIRES 1 YEAR PROM-DATE .ISSiTED Date Issued c� <br /> i r (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 incompliance with San Joaquin <br /> ' County Ordinance No. ,1862 ;,and the Rules and Regulations of the San Joaquin Local Health'District. <br /> E JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name LO j I. b <br /> _ Phone <br /> Address 6,C 4. r <br /> City , . � <br /> Contractor's Name <br /> License # Phone <br /> TYPE OF WORK (Check): NEWS,.WELL /? DEEPEN /-7 .RECONDITION /7 DESTRUCTION -7 <br /> PUMP INSTALLATION/ / PUMP REPAIR /) PUMP REPLACEMENT %f <br /> Other El <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> . SEWER LINES PIT PWE <br /> RIVY � <br /> SEWAGE DISPOSAL FIELD CESS OP OL/SEEPAGE PIT <br /> .INTENDED USE <br /> PROFERTY LINE - PRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL <br /> �� 'TYPE OF WELL CON <br /> trial. STRUCTION SPECIFICATIONS <br /> _. Indus �;, Cable Tool `t Dia. of Well <br /> =X Domestic/private .- ' Drilled Dia <br /> Domestic/public II ��" Driven . of Well :Excavation <br /> Casing <br /> Irrigation ;� Gauge of Casing .. <br /> Gravel Pack ' Depth of Grout Seal <br /> ------- Cathodic-, Protection I Rotary -- <br /> 'Disposal Type of Grout <br /> Geophysical ..... <br /> .- . <br /> Other �. ,u Other Information - <br /> Surface <br /> nformation - <br /> Surface Seal Installed <br /> 'B <br /> PUMP INSTALLATION: Contractor <br /> Type kof Pump <br /> PUMP REPLACEMENT: : <br /> . �`/� State Work Done <br /> PUMP :REPAIR: e StatWork Done , <br /> +�.� <br /> DES-TRUCTION OF WELL: Well Diameter U V <br /> _ Describe Material andProcedure Approximate Depth <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Heal <br /> th and the State of California-pertainingrto or regulating well-'construction. Within FIF'TEENtD # <br /> after completion of my wthe ''on a new well I will furnish the San Joaquin Local Health .District <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-af my.knowledge-and belief. I WILL CALL 'FOR A 'GROUT INSPECTION <br /> PRIOR TO GROU ING AND A FINAL INSPECT'IQX <br /> � ,;�".. TITLE <br /> (D W PLOT PLAN ONREVERSE SIDE <br /> PHAASSE_,1 FOR DEPARTMENT USE ONLY <br /> APPLICATION .ACCEPTED BY ` � ti: <br /> ADDITIONAL COMMENTS: <br /> DATE <br /> PHASE Ii. IN PECTION <br /> INSPECTION BY DATE PHASE III F' INSPECTION <br /> INSPECTION BY DATE r- <br /> �•E H,1426 � k <br /> =Rev. 1..74 <br />