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SAN JOAQUIN LOCAL HEALTH DISTRICT, <br /> EOFx OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. � <br /> Telephone: (209) 466-67$1 T Permit No, � s <br /> APPLICATION FOR WELL CONSTRUCTION OR PUNK' PERMI <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 Co construct <br /> and/or install the work herein described. TResapplication <br /> is the Sane3oaquincompliance <br /> HealthSan <br /> D3.strictin•, <br /> County Ordinance .No. 1862 and. the Rules and gula <br /> CENSUS TRACT <br /> JOB ADDRESS[LOCATION <br /> ` Phone 4 <br /> Owner's Name ¢ <br /> Address = /��i lc -� City <br /> License ,� 7 PO Phone <br /> Contractor's Name • T R <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN _/_I RECONDITION I� REREPLACEMENT_/rT <br /> PUMP INSTALLATION %f PUMP REPAIR / / PUNS � ' <br /> Other "./ <br /> C <br /> SEWER LINE <br /> + S L-1 J' PRIVY <br /> DISTANCE TO NEAREST: SEPTIC TANK C;R�OOL/SEEPAGE PTT, OTHER OE <br /> M-W SEWAGE DISP ""FTT�LD j <br /> PROPERTY LINE - PRIVAT DOMESTICWELL: _PUBLIC DOMESTIC WELL rr� <br /> INTENDED USE, , YPE' OF . ELL CONSTRUCTION �`SpECIFTCATIONS <br /> " ' Cable Tool Dia. of Well Excavatibn= `r <br /> I trial ri <br /> omestic/private. -u_D.rilled..,..�.,._ = Dia. _of .Well Casing"+ <br /> ki <br /> Domestic/public , <br /> Driven _Gauge-of Casing <br /> Irrigations -Gravel Pack Depth of Grout Seal �— <br /> �- `` �`` Rotary Type of Grout ;' <br /> Cathodic Protec't� o� y Other Tnformationri <br /> Disposal. k -: r , �,;„��� Other a <br /> Geophysical ! Surface Seal Installed By: <br /> I v <br /> PUMP INSTALLATION: Contractor <br /> F Type:. of Pump <br /> � <br /> PUMP REPLACEMENT:' 'State Work Done <br /> I I <br /> PUMP ,REPAIR: � . / / State Work Done <br /> DESTRUCTION OF WELL: Weli. Diameter <br /> Approximate Depth _ <br /> Describe Material and Procedure <br /> kI hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well''construction. Within FIFTEEN DA , <br /> after completion of my work an anew well, I will furnish the San Joaquin Local Health Distrigt a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use.. The above <br /> information true to the est of my knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> k, w� <br /> PRIOR TO GR G D A AL I SPEC'IION. f + <br /> TTTLE 1/ <br /> SIGNED <br /> (DRAW ULVI PLAN ON REVERSE SIDE <br /> F R DEPARTMENT USE ONLY <br /> t -7 <br /> PHASE I DATE <br /> 3 APPLICATION ACCEPTED BY <br /> F ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> PHASE II OUT INSPECTION <br /> k INSPECTION BY DATE INSPECTION BY <br /> : 1/77 . 2M <br />