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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �EO� OFFICE USE: <br /> 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na� <br /> �? <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 District for a permit to construct uiai <br /> and/or install the work herein described. This application is made in compliance with San Jo.oq <br /> County Ordinance No.. 1862 and 'the Rules and Regulations of the San Joaquin Local Health District. <br /> i <br /> JOB ADDRESS*LGGAT-189N I Z Lr CENSUS TRACT <br /> Phone <br /> Owner's Name <br /> l <br /> � - <br /> Address city <br /> License J;,*�hone <br /> Contractor's Name sf� <br /> i <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN / / RECONDITION I!T DESTRUCTION /-7 ; <br /> PUMP INSTALLATION '^' PUMP REPAIR I I PUMP REPLACEMENT I=T i <br /> Other Ll ------------------------- <br /> ] <br /> DISTANCE TO NEAREST: SEPTIC TANK ...SEWER LINES!040 f-PIT PRIVY <br /> rFecpnnT !SEEPAGE PIT OTHER a- <br /> SEWAGE DISPOS FIELD��- - -* ��� " <br /> PROPERTY LIN tPRIVATE DOMESTIC WELL '`- PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> r,,,_y,�. .t. --&f-Well <br /> _ Industrials_,.. -�'°- ' ' -- abld'Tool Dia. Excavati2sn�� <br /> Domestic/private Drilled 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 '---14 <br /> Disposal Other a Other..Information. <br /> Geophysical i Surf ace Seal Installed By'. 0 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> Approximate Depth <br /> IDES•TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure— <br /> lth <br /> rict <br /> re agree to comply with all laws and regulations of the San Joaquin LowilhinaFIFTEENtDAYS , <br /> I hereby g <br /> land the State of California pertaining to or regulating well construction. t <br /> ; after completion of my work on a new well, I will furnish the .SanJaqu <br /> heowel3ninouse.cal geThehaboverict a ` <br /> WELL DRILLERS REPORT of the well and notify them before 'Rutting <br /> , information is true to the best of- my- knowledge a d belief. I 'WILL CALL FOR A GROUT INSPECTION <br /> 1PRIOR TO GROUTING AND A FINAL INSPECTI E S 1 L <br /> SIGNED <br /> DRAW PLOT LAN ON REVERSE SIDE <br /> FOR D PARTMENT USE ONLY <br /> SE I ,[�'� DATE <br /> _,LICATION ACCEPTED BY C <br /> EADDITIONAL COMMENTS: pIASE III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE Y 7 <br /> 'I ` <br /> NSPECTION BY DATE <br /> l/.77 2M <br />