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s _ -- . <br /> JU , r,� <br /> SAN JOAQ'UIN. LOCM: 'ZEALTH �STRICT <br /> EIDE!-OFFICE USE: 1601 E. Hazelton- &6'i',''Stockton, Calif, <br /> Telephone:x: ..(209)..,-'456-6781 <br /> APPLICATION FOR WELL+CONSTRUCTION OR PUMP PERMIT Permit No.. 31d <br /> THIS PERMIT EXPIRES°1'-YEAR. FROM DATE ISSUED Date Issued <br /> (Complete ,In.:Triplicate) <br /> Application is hereby made to .the San Joaquin: Local-..Health Disttict for a permit to construct <br /> and/or install..the work herein described.,,. .This: appli�c,ation,is made in compliance with San Joaquin <br /> County Ordinance No. 186.2 acid the Rule :anI Regulati sof- he San Joaquin Local Health District. <br /> JOB ADDRESSAOCATION � <br /> �US TRACT <br /> Owi:er°s Name `y / <br /> Phone <br /> Address �.��. �..._.� . _ ... <br /> �� `city <br /> contractor's Name . S <br /> License #`f MVI Phone,33 ,? .3V3 <br /> IF <br /> TYPE OF WORK (Check): NEW WELL DEEPEN ,/7 RECONDITION /-7 . DESTRUCTION /_7 <br /> i <br /> PUMP INSTALLATION /% PdIMP REPAIR 1_7 PUNP REPLACEMENT /7Other /% <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY j <br /> SEWAGE DISP05AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC L'_ PUBLIC DOMESTIC WELL <br /> i . INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation i <br /> Domestic/privateDrilled Dia. of Well Casing <br /> Domestic/public Driven. Gauge of, Casing. _ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout' <br /> Disposal _ . Other Other, Information <br /> EM Geophysical Surface Seal Installed B <br /> PUMi - � <br /> P INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> P <br /> UMP '.REPAIR: .� . <br /> - //T State Work Done _ <br /> ES;TRUCTION OF WELL: Well Diameter Approximate Depth <br /> I� Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and1the State of California pertaining <br /> � p Hing 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 REPORT of the well and notify them before puttingthe well in use.. The above <br /> information is true• to the-beat of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION i <br /> PRIOR TO ROUTING AND FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> { <br /> PHASE� FOR DEPARTMENT USE ONLY <br /> I <br /> APPLICATION ACCEPTED BY �,b� DATE a ,s <br /> ADDITIONAL COMMENTS: <br /> AS <br /> PHASE II G70-UT INSPECTION PHASE III FINAL INSPECTIOIJ <br /> INSPECTION BY BATE INSPECTION BY DATE .� <br />} <br /> E. <br /> 8 Y1426 �. Rev. 1-74 ley <br />