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SAN JOAQUIN LOCAL, REALTH DISTRICT <br /> FOR OFF-T(:E USE:,7 1601 E. Hazelt6rOAve Stockton, Calif. <br /> _4 Telephone:.._:^(209).-i:4�ft 6781 <br /> 1s X APPLICATION FOR WELL CONSTRUCTION-i'OR PUMP PERMIT <br /> Permit No. <br /> THIS PERMIT,FXPzI.,RtS_';ItYEAR,fFROM_!:DATE�ISSUD,5.,;r- -' 'anDat'e`=I8 E§66d <br /> MA � <br /> e�e "1if- Triplicate) <br /> 40 <br /> Applicat.iQii�,-)ii3-),hbreby,-mad-eito 1th-e,,,Zav,1J'baqu'2:n Local W1 He' a 1_th D i.s t r.i:c t-�_ f r a C..,p e,rM` i t_,;t 0 nstruC'i <br /> and/or install the work here'in described. Th-is,-lappTldc.a:t,i:on-F-is,",madia,I in. compliance with.,San-,,,J-oaquin <br /> County-Ordinanc-er,i 01cl 186 andk";Re°gulaZivr.is­ofthe, -San',Joaquin.Loc a 't Healthy District. <br /> pro <br /> JOB ADDRESS ION A/M I& P&d I <br /> I U_ <br /> T 01:7 i W ..l lr�, Toj <br /> Owner�!.S_--oX. <br /> Address <br /> 7 ...... <br /> Contractor's Name License # Phone ' <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/ RECONDITION DESTRUCTION <br /> Pump - -MEN-_ /_7 <br /> AL TION PUMP REPAIR '/ <br /> PUMP REPLACEMENT <br /> _Other', <br /> DISTANCE TO NEAREST: SEPTIC-TANK- SEWER LINES ' <br /> PIT PRIVY <br /> SEWAGE D <br /> ISPOSAL, FIELD CESSPOOL/SEEPAGE PIT, OTHER <br /> INTENDED USE ' TYPE OF -WELL' 'CONSTRUCTION: SPECIFICATIONS <br /> Industrial j <br /> . . .Cable Tool Dia. ,of .Wel-l. Excavation <br /> Domestic/p'rivate K Drilled Dia'. of Well Casing <br /> Domestic/public-' DriVeri Gauge or Casing <br /> Irrigation. irel <br /> _Gra Pack Depth of, Grout, Seal <br /> Other _ Rotary Type of Grout <br /> T_T_ <br /> t. <br /> Other Other Inforination <br /> PUMP INSTALLATIONt. <br /> Type .:of Pump je H.P.i <br /> 4 <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: State Work Done <br /> .DESTRUCTION OF WELL: . .Well .Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply -with. all laws- and regulations of the San Joaquin Local Health DistrictV <br /> and � <br /> ,the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion 6fmy' work on a new well, I will furnish the San Joaquin Local Health Distric i t a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the be: st: of.my,knowledge and belief. <br /> SIGNED- TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED V yz- DATE 4e; <br /> ADDITI'G AL CONTS- <br /> ' <br /> S� <br /> * <br /> PHASE,I <br /> P I GROUT INSPECTION PHASE III/FINAL INSPECTION .- <br /> INSPECTION y <br /> PLI DATE INSPECTION BY f9jyc DATE <br /> OUT <br /> GALL OR A __ Q1JT INSPECTION, PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E �4T7-2 -1,M, <br />