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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOk OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif- <br /> FOR ' (209) 466-6781 Permit No. 7�. <br /> e APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> # Date Issued <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I (Complete In Triplicate) pe to construct <br /> Application is hereby mad ere it' described. Thisoapplication isthe San Joaquin Lcal Health trict made inrca compliance with San <br /> and/or install the work h Joaquin <br /> Count Ordinance No. 1.862 and,�.the Rules and Regulations of the San Joaquin Local Health District. � <br /> Y <br /> �QCENSUS TRACT <br /> JOB ADDRESS/LOCATION d <br /> Phone <br /> Owner s Name <br /> City <br /> Address � a r <br /> /� License #,:gdG�o4 Phone <br /> Contractor's NateG!''� J � <br /> DEEPEN / / RECONDITION_/ j DESTRUCTION /_T <br /> TYPE OF WORK (Check) : <br /> NEW WELL <br /> / PUMP REPAIR —PUMP REPLACEMENT /7 <br /> O� <br /> Other/ / O <br /> SEWER LINES_ PIT PRIVY <br /> DISTANCE TO NEAREST: <br /> SEPTIC - W CESSPOOLISEEPACE PIT - OTHER <br /> _. SEWAGE DISPOSAL FIELD L <br /> -DOMESTIC -WEI --- <br /> .. p-ROPERTY.LINE = PRIVATE„-DOMESTIC�WELLCONSTRUCTI pUpLICC SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL z <br /> Industrial Cable Tool Dia, of Well. Excavation <br /> Drilled Dia. of Well Casing <br /> Domestic/private Driven Gauge of Casing <br /> Domestic/public <br /> Irrigation Gravel Pack Depth. of Grout Seal <br /> Rotary Type-.of- Grout-�” <br /> Cathodic Protection Other Other Information <br /> Disposal Surfac "e"Seal installed B <br /> Geophysical <br /> PUMP INSTALLATION: Contractor - HP. , <br /> Type of Pump <br /> j pump REPLACEMENT: / / State Work Dome <br /> -. <br /> I PUMP .REPAIR: / / State Work Done _ <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well <br /> el DiameteDescbe r <br /> and Procedure — <br /> cal <br /> rict <br /> I hereby agree to comply with all law s and egelulatingowell'construction•f the San Joaquin LoWithin at <br /> FIFTEEN <br /> 1. and the State of California pertaining to o g <br /> after completion of my work an a new well, <br /> otif Tthemwill <br /> beforefurnish <br /> puttingatheJoaquin <br /> inLocal <br /> use... Thei�aboverrc <br /> WELL DRILLERS REPORT of the well and notify <br /> knowledge and belief. <br /> information is true to the best of my I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR T G AND A FT AL INSPECTION. TITLE ------ <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> a FOR DEPARTMENT USE ONLY 77 <br /> PHASE I DATE /— <br /> t APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE /FIN TNSPECTTON <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE <br /> INSPECTION BY DATE <br /> r y 6/77 2M <br />