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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> EAk.OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. / <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE'ISSUED Date Issued <br /> ` (Complete In Triplicate) i <br /> -Application isAereby made to� the San Joaquin Local. Health District for a permit to construct <br /> and/or install; the work herein described. This application ismade in compliance with San Joaquin <br /> County Ordinance No. 1862 and tb4 Rules and e ulatio of the San Joaquin Local Health Dist#ct. <br /> JOB ADDRESS/LOCATION6 C NSUS TRACT Wil. <br /> Owner's Name (�, 't1_. - LLQ Y �ftJ Phone <br /> Address City <br /> r � t <br /> Contractor's Name ", l License #a9 / Phone <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN '/_/ RECONDITION /_7 DESTRUCTION /'7 <br /> PUMP INSTAL vLATION / / PUMP .REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Q PIT PRIVY <br /> i SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER f -. <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 f" <br /> )( Domestic/private Drilled Dia. of Well Casing <br /> Domestic- /public - <br /> �P Driven Gauge of Casing <br /> -- Irrigation Gravel Pack Depth of Grout Seal'- - <br /> � ` ,Cathodic'Protection Rotary Type of Grout ; <br /> Disposal Other Other Information ; <br /> Geophysical Surface Seal, Installed BV: ! <br /> N4 5 . <br /> PUMP INSTALLATION: Contractor Al 0, S, + t <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT <br /> j_/ State Work Done <br /> k PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF' WELL: We11.Diameter ,.Approximate Depth <br /> //L Describe Ma eri l and P ocedur <br /> 62 <br /> G� �, AA a <br /> I hereby agree' to comply with all laws d regulations fl theme a Joaquln��Locgl Health District <br /> and the-State of California pertaining�-ta.,�ar.�regulat3ng we�l 'construction. Within FIFTEEN DAYS <br /> 4 after completion of my work on a new well,. I will furnish they Sano in�"Loca1""Aea th District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the 611-in-use.-.the above <br /> information is true to the best of. my knowledge and belie!-: WILL CALL FOR''",A`'GROUT .INSPECTION <br />;PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> RA PLOT PLAN ON REVERSE SIDE) <br /> # FO ;DEPART USE ONLY <br />'SPHASE I <br /> hAPPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS. <br /> PHASE GROUT INSPECTI N i P II IAL INSPECTI N <br /> INSPECTION BY . - DATE- r -—INSPECTION'BY - ---DATE' <br /> ..I� No. 101111711117; IR:; <br /> u ��� uo;, ,_��;. L) $ Jd' X17 <br /> t k-mv 1 <br />