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SAN JOAQUIN LOCAL UZALT4 DISTRICT <br /> F_0i7OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif.. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br />} THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued ,� AG 76 <br /> (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 in compliance with San Joaquin <br /> County Ordinance No. W862 and the Mules and gulations of the San -Joaquin Local Health District. <br /> JOB ADDRESS AOCATION I!RQ CENSUS TRACT <br /> Owner's Name ----_.&L n�� a.Qimu- Phone �„r 77f <br /> Address ■G �f/)VCity <br /> rrl ��'4•• �1�4 �r�+.F i . w.. w -. ilii r rir <br /> Contractor Name License U 1) Phone '26) <br /> TYPE OF WORK (Check): NEW WELL/� DEEPEN j-7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTZLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / — <br /> DISTANCE TO NEAREST: SEPTIC TANK 160 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial b49 Cable Tool Dia. of Well Excavation q <br /> Domestic/private Drilled Dia. of Well Casing7 \} <br /> Domestic/public Driven Gauge .of Casing Jam, 1,y� <br /> - "-- Irrigation Gravel Pack Depth of Grout Seal <br />€ Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other`Information <br /> Geophysical Surface Seal Installed 'By: `rumHIT <br /> AL <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump H.P. .. <br /> PUMP REPLACEMENT: .- -- / / State--Work Done_ �, W-9 <br /> PUMP REPAIR: % / `State-Work-Done <br /> DESTRUCTION OF WELL:", Well Diameter -- Approximate Depth <br /> Describe Material Arid Procedure <br /> I hereby agree to comply with all" laws and regulations-of the San Joaquin Local Health District <br /> and the State of California pertaining'to orregulating well-•construction. Within FIFTEEN DAYS <br /> 1after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting. the..well. in use... .The shave <br /> information is true to the-best-of my knowledge and belief. I WILL. CALL FOR A'GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> I SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE , <br /> ADDITIONAL COMMENTS: <br /> PHASE lI GROUT INSPECTION HA5 II INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br />