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k SAN JOAQUIN LOCAL HEALTH DISTRICT +, <br /> 3 <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> I Telephone: ' (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR -FROM DATE ISSUED Date Issued <br /> 7 (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Lnca1 Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin; <br /> County Ordinance No. 1862 and ithe Rules and Regulations of the San Joaquin Local Health District. <br /> JOS ADDRESS/LOCATION T'► VCENSUS TRACT <br /> Owner's Name Phone <br /> Address A mCity �✓ <br /> s <br /> n i <br /> License ��2�yl- AI Phone <br /> Contractor's Name <br /> TYPE OF WORK (Check) : NEW' WELL /�`Ifi DEEPEN /_/ RECONDITION iI / DESTRUCTION I=T <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other F � ° . ... <br /> Ot / . <br /> DISTANCE TO NEAREST: SEPTIC-:TANK SEWER LINES FIT PRIVY 7 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPACE PIT OTHER <br /> l T PROPERTY LINE - PRIVATE DOMESTIC WELL 3 PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ; Cableof Dia. of Well Excavation <br /> --T "t <br /> Domestic/private Drilled �Ikvi Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation y Gravel Pack Depth of Grout Seal �ti <br /> Cathodic Protection Rotary Type of Grout �-- <br /> Disposal Other __ Other Information <br /> Geophysical Surface Saal Installed B <br /> PUMP INSTALLATI-ON:-- Co.n.t-ra-c. ,Q <br /> Type of Pump �u - <br /> PUMP REPLACEMENT: / / State Work Done, p <br /> PUMP .REPAIR: � / / State Work Done <br /> DES•TRUCTIO.N OF WELL: WellitDiameter i,,, C,�. Approximate Depth/ <br /> _ .. C <br /> Describe 'Material and Procedure k 1 <br /> I hereby agree too comply .with, all laws and--regulations of the Sany'Joaquin Local Health District <br /> and the State of` Calif0tula pertaining to or regulating well 'coristruction. Within FIFTEEN DAYS <br /> after completion of my work on anew well, I will furnish the San Joaquin Local <br /> iealth District a <br /> before putting the well i <br /> WELL DRILLERS REPORT of the well and notify them n use.... The above <br /> information is true to the best of my knowledge and belief. �I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOGRO ING AND FIN INSPECTION. I <br /> TITLE <br /> SIGNED 7 �-. <br /> (DRAW PLOT PLAN ON REVERSE SID ) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I /D� DATE /p� '�'� . <br /> APPLICATION ACCEPTED BY ' <br /> ADDITIONAL COMMENTS: 6. PHAS�TI /FININSPECTION <br /> PHASE II GROUT, INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE J/- - -7 -- <br /> of7.7 2M <br />