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.. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif . <br /> ;s <br /> FOF%7OFF70GE USE ` <br /> Telephone: (209} 466-6781 Permit No. <br /> � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued <br /> (Complete In Triplicate) permitict to construct <br /> with,Application is hereby made herto ein <br /> described. This San Joaquin oapplication istmade inrcomplicaleHealthSDistrict. <br /> and/or install the work herein de <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Lo I <br /> GCJ CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> t Phone <br /> Owner's Name ! ' <br /> City { <br /> Address <br /> License .#� �.,*Phon <br /> Contractor's Name <br /> DEEPEN / / RECONDITION /_7 DESTRUCTION /7 ' <br /> TYPE OF WORK (Check) : NEW WELL I PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> PUMP INSTALLATION <br /> Other <br /> SEWER LINES � PIT PRIVY _�_� <br /> F HER <br /> DISTANCE TO NEAREST: SEPTIC TANK OESSPOOI/SEEPAGE PIT OT <br /> i _ - -- SEWAGE DI-SPOSAL"FIELD- 4 _ ,, 1 PUBLIC-DOMESTIC WELL <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL " <br /> TYPE OF LL CONSTRUCTION SPECIFICATIONS <br /> __4INE ED USE able Tool Dia. of Well Excavation -14F IL <br /> iF <br /> Industrial Dia. of Well Casing <br /> as <br /> Domestic/private Drilled 4 <br /> i Driven Gauge of Casing Do stic/public Depth of Grout Seal C <br /> rrigation Gravel Pack P <br /> Type of Grout ' <br /> Cathodic Protection Rotary Other Information <br /> Disposal Other <br /> .. �_ Surface Seal Installed B <br /> Geophysical ' <br /> r <br /> k PUMP INSTALLATION: Contractor H.P. , - <br /> Type of Pump <br /> __PUMP � .Work Done— <br /> PUMP <br /> one <br /> -REPLACEMENT State:.::- / <br /> - PUMP `REPAIR• State <br /> Approximate Depth <br /> f DESTRUCTION OF WELL: Well Diameter <br /> _ Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> tinWithin FIFTEEN <br /> and the state of California pertaining to °� jrril7ulfurngshethecSantJoaquin.Local Health Dist C' <br /> after completion of my work on a new well, in use. <br /> WELL DRILLERS REPORT of the well and m notify <br /> yethem beforend u p' tt.�I WILL CAing the FOR A GROUTeINSPEC ION <br /> information i true to the t of Y ry _ . <br /> PRIOR TO CRO NG AN A F I P CT 'ON'. TITLE <br /> i SIGNS➢ (D PLOT PLAN ON REVERSE SIDE) # <br /> I FOR DEPARTMENT USE ONLY <br /> PHASE I DATE � — 7 <br /> APPLICATION ACCEPTED BY e- <br /> ADDITIONAL COMMENTS: pHp,SE III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION ATE <br /> INSPECTION BY DATE INSPECTION BY <br /> �� <br /> IT l_7ZL <br />