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SAN JOAQUIN LOCAL.HEALTH DISTRICT <br /> OFFICE USE: '' ✓ 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> FOE. <br /> Telephone: (209) 466-6781 '2 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. { <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1 <br /> (Complete In Triplicate) <br /> Application isAereby made to the San Joaquin Local Health Dist is rin compliance it tconstruct <br /> Pp <br /> ncewith SanJoaqu n <br /> and/or install the work herein described. This application s <br /> County Ordinance No. 1$62 and the. Rulea and Regulations of the San Joaquin Local Health District. <br /> + � CENSUS TRACT <br /> JAB ADDRESS/LOCATION <br /> i Phone <br /> Owner's Name <br /> City ,— <br /> Address <br /> ity Address O 0 <br /> .License # 3 0'703 Phone <br /> Contractor's Name <br /> TION � <br /> DESTRUC 1 - <br />' TYPE OF-WORK (Check) NEW WELL / /�DEEPEN <br /> / / ��NDITION_ _/ T ,� . <br /> PUMP INSTALLATION / PUMP REPAIR J / PUMP REPLACEMENT I7" <br /> Other t/ / �' <br /> DISTANCE TO NEAREST: OQ <br /> SEPTIC�TANK SEWER LINES IT PRIVY <br /> SEWAGE�.DISPOSAL FIELD CESSPOOL/SEEPAGE PIT` . ' OTHER <br /> PROPERTY LINE - PRIVATE I)OMESTIC WELL PUBLIC DOMESTIC WELL <br /> f INTENDED USE {TYPE OF WELL <br /> .CONSTRUCTION SPECIFICATIONS <br /> Industrial - •�' a - Cab1eyToo1 - 'Dia:-�of Well ExCavatfon <br /> f Dia. of Well Casing - <br /> Domestic/private.` �� Drilled V. _ - <br /> ublic T <br /> 'Driven Gauge of- Casing <br /> Domestic/public <br /> omeIrrsttion �,_ . ,m...,�.� Gravel Pack-�-Y-DePth-of Grout:S0&1 = <br /> 1- N� -Type`of' Grout <br /> Cathodic Protection Rotary„,.- "-' Other Information <br /> Disposalt. 6--t --�Other <br /> Geophysical - , " ' ' Surface Seal Installed B <br /> �• <br /> ti a <br /> PUMP INSTALLATION'. Contiractor H. %8 <br /> ' Typeiof Pump <br /> � o <br /> k PUMP REPLACEMENT: r <br /> State Work Done <br /> PUMPREPAIR• / State Work_Do-ne <br /> . <br /> i <br /> w -- ` <br /> Approximate Depth ' <br /> --r=� <br /> I DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> tict <br /> ` San oaq, <br /> I hereby agree to cbmply with all° laws, and r2regutati owelleconstruction:LoWithin aFIFTEEN tDAYS <br /> and the State of California pertaining to or regulating <br /> after completion of my work on a new well, I will furnish the San Joaquin Local EeThe. District e <br /> above <br /> WELL DRILLERS REPORT of the well and notify them <br /> andbefore <br /> beliefputting <br /> I WILL'CALL FOR A GROUT�INSPECTI <br /> information is true to-the best of my knowledge <br /> PRIOR TO GRO TING'-AND A' F NAL 'INSPECTION. TITLE �� <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> x - FO DEP MENT USE ONLY <br /> PHASE I a J DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS:' PHASE ill/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE <br /> INSPECTION BY ' DATE <br /> �6-1f , 1{77 <br /> n u „qK 10-1 1,74 �. ' <br />