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rhrtj- <br /> SAN JOAQUIN LOCAL HEALTH DISTRCCT <br /> alif . <br /> 160L, E- Hazelton Ave. , Stockton, <br /> FOR OF Z E SSE: Telephone : (209) 466-6781 Permit No. 7: <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT -7 <br /> Date <br /> iDate Issued <br /> THIS PERMIT EXPIRES l YEAR FROM .pATE ISSUED <br /> (Complete In Triplicate) ermit to construct <br /> Application is hereby made to tdescribedSan aquThis�applflicatiangistmade inrcomp <br /> fiance with San Joaquin <br /> , <br /> and/or install the- work herein ulatioris of the San Joaquin Local Health District. <br /> County Ordinance No:. 1862 and the Rules and Reg CENSUS TRACT: 1 <br /> JOB ADDRESS/LOCATION <br /> 'Phone <br /> Owner's Name <br /> City <br /> k Address Phone <br /> 1 License <br /> fff Contractor's Name 6-4/ <br /> . DESTRUCTION <br /> NEW WELL / DEEPEN/ / RECONDITION / <br /> TYPE OF WORK (Check) : PUMP REPAIR / PULP REPLACEMENT IXI <br /> PUMP,]INSTALLATION .� <br /> 0 thea �---- <br /> � PIT PRIVY <br /> SEWER LINES OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK CESSPOOL/SEEPAGE PIT ��_ <br /> SEWAGE DISPOSAL FIELD PUBLIC DOMESTIC WELL <br /> PROPERTY LINE -- <br /> PRIVATE DOMESTIC WELL CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL { <br /> Cable Tool Dia. of We11 .Excavation <br /> Industrial Dia. of'Wel1 Casing <br /> _ x Domestic/private Drilled <br /> { Driven Gauge of Casing <br /> Domestic/public Depth of Grout Seal ` <br /> Irrigation <br /> Gravel �Pack <br /> IP <br /> Rotary Type of Grout <br /> Cathodic Protection Other Information <br /> Disposal Other <br /> Surface Seal Installed B <br /> �r Geophysical �I <br /> F PUMP INSTALLATION: Contractor H.P. ` <br /> t Type of Pump f4 <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: - " ' ' /- �f.. State Work Done <br /> t Approximate Depth �� <br /> DESTRUCTION OF WELL: Well Diameter --- --- <br /> �, — Describe Material and procedure <br /> e with all laws and regulations of the San Joaquin <br /> o quin.LoWithznaFIFTEENCDAYS <br /> . i hereby rict <br /> agree to comply <br /> and the State of California pertaining to or regulating well c <br /> after completion of my work on a new well, I will furnieforesh the puttingatheowellninouse.. Thehaboverict <br /> WELL DRILLERS REPORT of the well and notify them b P <br /> I information is true to the best of- in knowledge belief- I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO -GROU ING AND A FINAL INSP CTI ITLE <br /> SIGNED <br /> (D W LO AN ON,R FRSE SIDE} <br /> f FOR DEPARTMENT USE ONLY W <br /> PHASE I. DATE IdZL�— <br /> k APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> PHASE IIGR� INSPECTION INSPECTION BY /! DATE • ' • <br /> INSPECTION BY DATE <br /> 6/%] _ 2M <br />