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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOfx;OFFICE USE: 1601 S. Hazelton Ave. , Stockton, <br /> Telephone: (209) 466--6781 Permit No. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT ?tea <br /> ;.� Date Issued Z 9 <br /> THI'S PERMIT EXPIRES 1 YEAR FROM DATE ISSUED y <br /> z <br /> (Complete In Triplicate) l3 1 - -(f <br /> to App <br /> lication ie Hereby made- to the San Joaquin Local cation istmaade in co pliance with San uJoaquiriIi <br /> a <br /> and/or install the work herein described. This PP <br /> : County. <br /> Ordinance No. .1862 ari� the Rules and Regulations of the Saar Joaquin Local Health District- <br /> r b K ✓ d� jr�/ Nsusy TRACT <br /> JOB ADDRESS AOCATION A <br /> f� Phonegz/ 3� <br /> c .1 .- <br /> . Owner's Name r A�G9"� <br /> Cit <br /> Address <br /> Phot <br /> License _---- <br /> Contractora <br /> TYP F WORK(heck): , NEW�WELL - DEEPEN l-7 RECONDITION �T DESTRUCTION <br /> _ . <br /> pU�lPINS�ALLATION /� PUMP REPAIR /� UMP. REPLACEMENT <br /> other <br /> PIT PRIVY <br /> DISTANCE,,TO- NEAREST:- SEPTIC TANK .SEWER LINECESSPOOL/.SEEPAGE PIT f OTHER i <br /> I p SEWAGE DISPOSAL,FIELDPUBLIC DOMESTIC WELL L <br /> - PROPERTY LINE - PRIVATE DOMESTICLLCONSTRLTCTION SPECIFICA ONS ` L <br /> TYPE OF WELL <br /> r TNTENDED USE - y able Tool Dia. of We11 Excavation <br /> i Industrial \,, , .. Dia. of Well Casing <br /> Domestic/private Drilled <br /> Uou�stic/public Driven Gauge of Casing <br /> Gravel Pack Depth of Grout Seal S ti <br /> Irrigation Type of Grout <br /> Cathodic Protection '� Rotary Other Information ' j <br /> Disposal Other �,_ . r <br /> 4 Geophysical Surface Seal Instal d Y. <br /> t�C <br /> PUMP INSTALLATION: Contractor H.P. <br /> Typ i of Pump <br /> PUMP REPLACEMENT: . I/' <br /> State Work Done <br /> LPUMf'. REPAIR: - /7/_—State State Work-Done <br /> " <br /> Approximate bepth <br /> DES;'fRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure �+ �; <br /> to comply with all laws and regulations of the San Joaquin Local Health District <br /> I hereby agree, p y <br /> and the State of Callforna 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 HealthDistrict <br /> WELL DRILLERS REPORT of the well and notify them before putting-the-well- in-use- <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. TITLE - <br /> SIGNEDU <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FO PARTMENT USEONLY <br /> PHASE I -- <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: s Pig NSPECTION <br /> PHASE II GROUT INSPECTION DATE �� - res <br /> INSPECTION BY i DATE INSPECTION BY <br /> a. <br /> Gil <br />