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r / 5AN UUAQUIN .LUCAL HEAL I H Ul5 I M U I (lR 'OFFI 'E USE: v 1601 E. Hazelton Ave.,, .Stockton, CA 95205 Permit No. —, Telephone:.. "(209) 456-6781 ALICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date issued Xy,- 4 1 T 1. 1 .. ,PP This Permit Expires 1 'Year From Dai;e Issued. f Complete.Fn Triplicate A plication is hereby made 'to Jthe San Joaquin .Local Health District for a .permit to construct and/or ;install the'work herein described. :,This application is made in compliance •with :San Joaquin County,.Ordi'nance. No,. 1862 -and the Rules and .Regulations ,of the San Joaquin .Local. Health � District. EXACT' STREET ADDRESS a , D file CITY/TOWN ' 1 Owner' s Name Phone Address . City 99 .-Contractor' s Name License 1 '? Pt = TS -CERTIFICATE OF WORKMAN'-S COMPENSATION -I`dSURA1.10E ON- FILE WITH SJLHD? ._YES `FJO TYPE OF WORK (Check) : NEW WELL tq,- DEEPEN ❑ RECONDITION Q DESTRUCTIONI� WELL CHLORINATION ❑ WELL ABANDONMENT a OTHER PUMP INSTALLATION 0 PUMP REPAIR❑ PUMP REPLACEMENT ❑ D.ISTAIVCE TO NEAREST: SEPTIC TAN /gEWER LINES PIT PRIVY SEYJAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER PROPERTY LINE --PRIVATE PRIVADOMESTIC WELL PUBLIC DOMESTIC WELL r INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS . 61 Industrial Cable Tool Dia. of Well Excavation � Romesticf pri vate Drilled Dia. of Well Casing Domestic/public Driven Gauge of Casing Irripatiori .,� Gravel Pack Depth .of Grout Sea C� 02 Cathodic._Pr-o�tection Bary Type of Grout Disposal f '. -Other Other Information Geophysical Surface Seal Installed by: •� ,.� .�. . . . ;1 - ,. PUMP INSTALLATION: Contractor x a Type of Pump H.P. _ PUMP REPLACEMENT: C]State Work Done PUMP REPAIR: ❑State Work Done � DESTRUCTION' OF WELL: Well Diameter Approximate Depth Describe Materia .and Procedure—. I hereby certify that I have prepared this application- and that the work will '-be done in accordant with San Joaquin County Ordinances , State Laws,,;