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/ P JOAQUIN LOCAL HEALTH DISTRICT <br /> Cfi <br /> OFFICE USE: L 1601-f. Hazelton Ave. , Stockton, Calir: <br /> v v,, _ Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7LW <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> plication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> d/or install the work herein described. This application is made in compliance with San Joaquin <br /> unty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> B ADDRESS/LOCATION .�i,`'Vl• /� Yyw-U,c�/�'S�vJ! u••�-' ---��-r�•��� a�-�-' CENSUS TRACT <br /> i v <br /> net's Name I _ Phone f 3. G 03 <br /> 7 o <br /> dress b,J A, / City <br /> ntractor s Name <br /> License # '' Phone k2 --26 <br /> PE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION DESTRUCTION DESTRUCTION /� <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /� <br /> Other <br /> .STANCE TO NEAREST: SEPTIC TANK /5'4, SEWER LINES PIT PRIVY \ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL (ti <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _ Cable Tool Dia. of Well Excavation \ <br /> _ Domestic/private Drilled Dia. of Well Casing /y' (� L •(. �d d' <br /> Domestic/public Driven Gauge of Casing la 99 <br /> Irrigation Gravel Pack Depth of Grout Seal ��— <br /> _ Cathodic Protection Rotary Type of Grout C'. ,,::.� N <br /> Disposal Other Other Information <br /> _Geophysical Surface Seal Installed By: 9�M„�-a../ p <br /> IMP INSTALLATION: Contractor `\ <br /> Type of Pump H.P. <br /> JMP REPLACEMENT: / / State Work Done <br /> UMP REPAIR: / / State Work Done <br /> 3STRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure 42 <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> id the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> fter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> 7-LL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> aformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTIO <br /> ,IOR TO GROUTING AND A FINAL INSPECTION. <br /> IGNED TITLE r <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> 'RASE I � <br /> LPPLICATION ACCEPTED BY /f `iy �'� � — DATE <br /> LDDITIONAL COMMENTS: <br /> PHA II RO INSPECTION PHA II FINAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION B .r f DATE <br /> r <br /> h/75 2M <br />