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Sr, OAQ, -N LOCAL HEALTI: DfSTRICT <br /> LK-OFFICE USE: 1601 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 _ _] <br /> (Complete In Triplicate) <br /> lication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> /or install the work herein described. This application is made in compliance with San Joaquin <br /> )unty Ordinance No. 1862 and the Rules and Re ulation of the San Joaquin Local Health District. <br /> Q <br /> ADDRESS/LOCATION / `" 0 -f '0131- -�V'l W of KoS--rc rZ Rt <br /> CENSUS TRACT <br /> +�er's Name h CJ h t ru <br /> X35- 7- 7YL <br /> Phone <br /> i�Tress 33b0o /CUS rE Jle_ y C/ . e-ec 1 <br /> City <br /> tractor's Name HQ A/ /V / /u s, PO ��016)3 i t2— /d3 j <br /> r <br /> License $ Phone <br /> E OF WORK (Check) : . NEW WELL / .j DEEPEN /_% RECONDITION /_7 DESTRUCTION /77 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> TANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT .PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE` PRIVATE DOMRSTIC WELL PUBLIC DOMESTIC WELL _ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFIC <br /> ATIOjyS <br /> Industrial Cable Tool Dia of Well Excavation',di, <br /> Domestic/private Drilled Dia.;'oWell Casing <br /> L Domestic/publicy Driven Gauge of,_Casing <br /> Irrigation Gravel Pack Depth Grout Seal <br /> Cathodic Protection Rotary Type;'of Grout <br /> Disposal Other Other 'I"formation <br /> Geophysical Y` + Surface Seal Installed By: <br /> ii.. <br /> _r <br /> FMP INSTALLATION: Contractor -- '+ <br /> Type of Pump H.P. <br /> y <br /> FMP REPLACEMENT: <br /> /§/ State Work Done <br /> ! 4 <br /> f► ? '.REPAIR: <br /> . _.___//,:.State._Wark_,Done. . _ __._ ..,., i,�_.-�.:__ „.�.__._ __•,� �..-.a_. <br /> gTRUCTION OF WELL: Well Diameter ik Approximate Depth <br /> VDes crikgClv�te1rfa`i and Procedure <br /> it r, <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> i'y the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> '(►er completion of my work on a new well, I will furnis,� the San Joaquin Local Health District a <br /> :LL DRILLERS REPO of the well and notify them before q,utting the well in use. The above <br /> Drmation u o the.best of my knowledge and belief, I WILL CALL FOR A GROUT INSPECTION <br /> LIR TO GRO AL INSPECTION. <br /> .GNED - �} TITLE <br /> ( W P OT P ON REVERSE SIDES----S <br /> 1 <br /> USE ONLY j <br /> IAS y ; <br /> 'PLICATION ACCEPTED BY DATE <br /> LITIONAL COMMENTS: I <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> fSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 <br />