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y <br /> SAID. JOAQUIN LOCAL HE&M TRICT <br /> fr'01r OFFIg USE:" : 1601 E. Hatelton Ave. Stockton Calif <br /> k Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTIONOR PUMP PERMIT Permit No. <br /> THIS PERMIT WIRES 1 YEAR FROM DATE ISSUED` Date'Isaued,?__� <br /> (Complete In Triplicate) <br /> Application is hereby made to the San 7oaquin Local Health District ,for a permit; to construct <br /> and/or Install the work hereindes€gibed. This application is made in complianea .with San Joaquin <br /> County Ordinance No. 1862 and the, Rules snd Regulations of the Sao Joa4uin Local Health District. <br /> JOA ADDRESS/LOCATION q- �C, MSUS T AM, <br /> Owner's Name t Phone <br /> Address Ci <br /> ti+ <br /> Contractor's Name <br /> �,icense ,f a hoses, <br /> —77 <br /> TYPE OF WORK (Chec.�c) : NEW,WELL_' DEEPEN _/�.' TION <br /> — , <br /> PUMP INST�LATION` PW REPAIS < PUMP REPLACEMEN' g <br /> •.•• <br /> Other / j <br /> DI TANCE ;TO NEAREST: SEPTIC TANKSEWER LIFE .. PRIVY <br /> SEWAGE DISPO FIELI3 CESSPOOLjsiQE PIT OTHER <br /> s PROPERTY L -- PRIVATE DOMESTIC InIlL PUBLIC DOMESTIC WELL <br /> 'IN49NDED USE TYPE O.F WELL IICTION SPE Irl loom; <br /> dustrial LelC"able' Tool Dia-*' "of ovation <br /> Domestic/private. Drilled Dia. Well. Casing <br /> Do*stic/public 4 <br /> Driven Gain of Casing <br /> IrrigationGravel Pack Depth of Grout Seel <br /> 'Cathodic Protection Rotary Typeof Grout <br /> Di s osal Other Other Information <br /> Geo hysical f Seal Instal e <br /> PUMP INS LATION: Contractor <br /> Type of Pump H.P,, <br /> PUMP REPLACEMENT: / ,/ . state Work.penq <br /> �rMoo <br /> - <br /> PUMP .REPAIR: jam• State Work 'Done <br /> DESTRUCTi OF WELL: Well D ate`r Approximate Depth; <br /> Desc a era, and Procedure <br /> I hereby agree to comply w hal -Taws and regulations of the San Joaquin Local alt �Districr; <br /> and the State of 'California, pertainin to or regulating well,."construction. Within FIFTEEN DATS" <br /> after completion of .my work on anew well, I will furniih t�. Sam, Joaquin Local Health DI a. <br /> WELL DRILLERS REPORT of the well and.notify them �befq.re thl.l. in use: ° The above <br /> information is us to the be of my knowledge avid"j) i:� t I T,J; . FOR,A UT INSI? C ION <br />?RIOR TO GROUT D FIN SP CT ION, <br /> Siam 41 <br /> DRAM PT PLAN ON' REV SEID <br /> R DEP T U ONLY <br /> PHASE"I - ----� � . <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMTS: 17 <br /> PHAU II GROUT INSPECTION PHASE II F AL <br /> INSPECTION BY DATE INSPECTION BY DAT <br /> Y <br /> E H 142,0 l- <br /> • lf <br />