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# i <br /> �? SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> kFOR �OFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephones (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT .EXPIRES 1 YEAR,FROM DATE.ISSUED Date. Issued S _/ _ a� <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local, Health District for a;permit toc�onstruct <br /> County Ordnance No. lk herein described. Thin application is made in__compliance with.�San Joaquin <br /> and/or install the work <br /> 862 and the Ririe® and Regulations of the San:Joaquin Local Health.,:District. <br /> F yT 6. i 1 1 r -("CENSUS ''RA <br /> CT <br /> T .ADDRESS/LOCATION <br /> JOB ADDRESS/ <br /> Owner's'Name Z.,�. t 41 <br /> T- Phone <br /> .150 <br /> Address "' +/� Y� ~ . . - <br /> Em <br /> City k <br /> Contractor's Name <br /> ' Lic�:nse # � : �Phone�l�. � <br /> TYPE OFWORK (Check) : NEV WELL EEPEN / RECONDITION /7 .DESTRUCTION !7 <br /> z PUMP INSTALLATION 7 .PUMP REPAIR -/-7—pump REPLACE ENT /7., <br /> `. a 'Other <br /> -DISTANCE TO NEAREST:. :=SEPTIC .TANKSnjftL SEWER LINES PIT PRIVY <br /> 4. ,,.=SEWAGE DISPOSAL FIRLD: CESSPOOL/SEEPAGE PIT p `' OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC-WELL - - PUBLIC ZOMEST-IG WELL <br /> INTENDED •USETYPE 0 ..WELL CONSTRUCTION/SPECIFICATIONS <br /> Industrial Cable Toon Dia, of Well Excavation0;orm <br /> Domestic/pr?�yate - � Drilled Dia. of Well. Casing <br /> Domestic/public ` f Driven Gauge of, Casing_;' ° <br /> Irrigation Graved Packm Depth of i'Grout Seal" <br /> Cathodic Pro'tec•tion`. °. Rotary Type of .GroatY 5r <br /> Dispersal . Oiher Other Information ' ' <br /> Geophysical <br /> _.Surf -Sea3"Tns ailed B <br /> PUMP <br /> INSTALLATION." Contractor <br /> Type -of. rpump + w <br /> PUMP REPLACEMENT. ' - <br /> State Werk`Dvne� <br /> r <br /> P.UMPL`:REPAIR: state Work DoneT w* <br /> DESTRUCTION OF WELL:;, Well Diameter „ "A.ppxoximate Depth <br /> Describe Materiat and Procedure _ - <br /> - <br /> I,hereby agree to comply with a'll laws and regulations,;of the Sari'Joaquin Local Health District <br /> And,--the` State of California-pertaining to or regulating well *-construction., Withiii.YIFTEEN-DAYS <br /> after completion of my work on a new well, I will fq�mish the .San 'Joaquin Local `Heal.th­Distr- ct a <br /> WELL DRI'LLERS'"REFORT of the well -and notify -them Before put'tinge..the"wel�.'iti:use:.. The above <br /> information is true..,to;.the;bent..of' my..knowledge and belief.' I WIft CALL FOR A.:GROUT INSPECTION <br /> PRIOR TO GROUTING AMY A 'FINAL INSPECTION. <br /> SIGNED <br /> T:ITLE" t <br /> (DRAV,PLOT PLAN ON' REVERSE-SIDE) ,-.,- {{ <br /> PHASE Z FOR DEPARTMENT USE ONLY i <br /> r <br /> APPLICATION ACCEPTED BY ... . . i DATE �� / L:I•`' <br /> ADDITIONAL COMMENTS: <br /> PH4W. GROUT INSPECT ON PHASE IIT FINAL INSPECTION <br /> INSPECTION BY }tz,4 DATE INSPECTION BY-4./o �!' Wil_ DATE <br /> E H 1426u, s - <br /> Rev. . { /75 - <br /> 2M = . <br />