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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> P <br /> FOIA OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Cali <br /> f. <br /> . 1 --1. Telephone: (209) 4664781 Permit -No. ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> I <br /> . Date 'Issued <br /> TRIS PERMIT E ;:i�_ <br /> XPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) <br /> ermit to construct <br /> isrict <br /> PP <br /> A lication is hereby made to:the San Joaquin Local Hedlth D istmade inrco p]iance with- San Joaquin <br /> and/or install the work herein described. This apP <br /> Rules and Regulations of the San Joaquin Local Health District, <br /> County Ordinance No. 1$62 and the <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> Phone •3s <br /> Owner's Name <br /> City <br /> Address ' , <br /> G�.� <br /> License #24-�t�_3Phone �-� .3 <br /> Contractor's Name <br /> a <br /> / / DEEPEN / / RECONDITION / DESTRUCTION <br /> I. TYPE OF WORK (Check) ; NEW WELL _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / - - <br /> DISTANCE TO NEAREST: SEPTICITANK SEWER LINES <br /> PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOol,/SEEPAGE PIT OTHER <br /> Y PUBLIC DOMESTIC WELL <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL <br /> {TYPE OF WELL �'��•"" <br /> INTENDED USE F'. Dia. of Well ExcIndustrial II Cable Tool <br /> rivate � <br /> 1 DrilledDia. of We]_1 CasDomestic/p Driven Gauge of CasingDomestic/public FIrrigation ! GpPack Depth of GroutS <br /> Rotary Type of Grout <br /> Cathodic Protection Other Information <br /> Disposal f <br /> Other u <br /> Surface Seal Installed <br /> Geophysical B <br /> I ' <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type'i of Pump - - --- <br /> k PUMP REPLACEMENT: / / State Work Done <br /> State Work Done <br /> PUMP REPAIR: / r l <br /> Approximate Depth <br /> k DESTRUCTION OF WELL: /'Well Diameter / �a �� hGH <br /> Describe terd Procedure u Y <br /> uin <br /> I hereby agree to comply with .all las rict <br /> ��do�eg�g���t��gowelleconstrucSan tion.LoWithinaFIFTEEN tDAYS <br /> and the State of California pertaining <br /> after completion of my work on a new well, Ithemlbeforesputtingh the athepwell ninouse... The habove <br /> rict <br /> WELL DRILLERS REPORT of the well and notify <br /> of m (knowledge <br /> information i5 tru to the1best and belief. TWILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR IN D FINA TI N. <br /> F.� , , TITLE se .r(e!� <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I l DATE <br /> APPLICATION ACCEPTED BY I' ' <br /> ADDITIONAL COMMENTS: t PIIAS II/_FINAL INSPECTION <br /> PHASE 11 GROi3T INSP CTION INSPECTION BY DAT <br /> INSPECTION BY DATE <br /> 0/77 - 2M <br />