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SAN JOAQUIN LOCAL HEAL RDS RICT <br /> FOE OFFICE USE: 10 L V1601 E. Hazelton Ave. , Stockton, Calif. 6� <br /> 1 ;. <br /> Telephone: {209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Pet'iit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued v '3- <br /> (Complete In Triplicate) <br /> Application is hereb de to the San Joaquin Local 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 the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRAC C ('° <br /> Owners Name 1V Phone �- <br /> Address ' City <br /> i A <br /> License Phone %471-0'F�q� <br /> Contractor s Name V-\ - <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN. ./� RECONDITION /_/ DESTRUCTION /_ <br /> AL <br />' PUMP INSTLATION PUMP REPAIR/ / PUMP REPLACEMENT 1-7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK S, fA SEWER L NES KEIT PRIVY <br /> SEWAGE DISPOSAL FIELD � ,-f-CESSPOOL/SEEPAGE PITT OTHER <br /> _ PROPERTY LINE - PRIVATE DOMESTIC�WELL PUBLIC DOMESTIC WELL �. <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS • <br /> Industrial -:_:; Cable Tool_:: Dia. of-Well-Excavation.. / T („ <br /> :::_�Domestic/private Drilled Dia. of Well Casing Q <br /> Domestic/public Driven Gauge of Casing ! <br /> i Irrigation Gravel Pack Depth of Grout Sea <br /> f Cathodic Protection !� xotary Type of Grout T _ <br /> Disposal Other Other Information <br /> f Geophysical` Surface Seal Installed BY: P <br /> PUMP INSTALLATION: ContractorI�S��k CO- f <br /> ` Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR-' F ., ; '" State Work Done <br /> + DES,TRUCTION OF WELL; Well Diameter Approximate Depth <br /> + Describe Material and Procedure <br /> I "hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining 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 %TOOUTING <br /> RS REPORT of the well and notify them before putting the well in use. The above <br /> inforis true to the-be m knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR AND A FI AL I N. <br /> SIGNED t TITLE <br /> W <br /> POT PLAN ON R$ FRSE SIDE) <br /> ,.FOR, DEPARTMENT <br /> PHASE ATE <br /> APPLICATION ACCEPTED Y D <br /> ADDITIONAL COMMENTS: PHASE /FIN INSPECTION <br /> PRASE91I GRO T INSPECTIO <br /> T�TSPECTIflN BY TE L INSPECTION BY DATE <br /> �.� <br /> E H 1426 Rev. 1 .74 s :; ,# � , - ---6� <br />