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R � C <br /> # SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 176 OFFIC£ USE: _, <br /> ---------- Ib(? flazelton Ave. , Stockton, Calif. <br /> ---�- Telephone: (209) 466-6781 Vl�_ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Trip'Icate) <br /> Application is Kereby 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 Saes Joaq <br /> County Ordinance Na. 1862 and the Rules N 6 a d Reggulations o the San Joaquin local alth Distriet. . <br /> I N L?r4 Rn O 1* _ ; <br /> JOBADDRESS/I.QCATION � W HOL7�e A'T-- <br /> J � CC R�►� � <br /> Nmer's Name <br /> °.i Phone <br /> ;= Address <br /> City , . <br /> .., ------�..--ter. <br /> Contractor's Nan* <br /> Yy: License 1'3� phone <br /> , <br /> TYPE OF WORK (Check): _NEW WELL /? DEEPEN / RECONDITION G DESTRUCTION �f <br /> PUINSTALLATION REPAIR <br /> /? <br /> 7� PUMPREPLACEM$NT <br /> Other J9F <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT- <br /> ' OTH$R9 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL UBLIC DOMESTIC WELL�� C~ <br /> INTENDED USE TYPE OF <br /> k" WELL CONSTRUCTION SP$CIFICATI <br /> ' Industrial Cable Tool Dia. of Well Excavation ON <br /> Domestic/private Drilled { <br /> Dia. of well Casing <br /> '^ <br /> Domestic/public Gauge o£ Casing <br /> j p Driven <br /> x' Irrigati,�n Gravel PA1.ck Depth of GroutSeal3 <br /> {� Cathodic Protection Rotary <br /> Dispor3l Typo of Grout <br /> _Geophysical Other Other Incormatien <br /> �, <br /> 5 Surface -Se 1 Installed B : '{ <br /> w PUMP INSTALLATION: Contractor ' <br /> �? Type of Fu <br /> mp <br /> _ ! H.P. , <br /> PUMP REPLACEMENT; x <br /> / / Stute Work Done <br /> PUMP -REPAIR: /? State Work Done � <br /> DES-TTpUC'TIAN. OF WELL: Well Di4meter <br /> Describe Material, and Procedure Approximate Depth � <br /> ` <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health istriet i '1 <br /> and the State of California pertaining to or regulating well'construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS RT of the well and notify them before putting the well in use. The above <br /> infarmati0 I <br /> e o the best of my knowledge and belief. I WILL CALL FOR A GROUT I <br /> NSPECTION <br /> PRIOR TO A FINAL. INSPECTION. <br /> SIuNEQ TITLE j <br /> DRAW PLOT P "It <br /> LAN ON REVERSE SID <br /> _PHASE I r'�J �FOR DEPAR' MENT USE ONLY E <br /> APPL47CATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: r DATE <br /> PHASE I'_ GROUT IN;, TION <br /> INSPECTION BYPHASE II FINAL INSPECTION <br /> INSPECTION BY ATB <br /> E N 1426 Rqv. 1-74 /77 21! <br />