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rt <br /> SAN JOAQUIN LQCALrUEALTH DISTRICT <br /> Al <br /> FFICE USE: 1601 E. Hazelton 4e`. , Stockton, CA 95205 Permit No. 3.3 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued /-� 7 <br /> 1 (Complete In- Trip h i e) <br /> 11 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to`,construct <br /> and/or-.install the work herein described. This application- is made in compliance with San <br /> Joaquin County Ordinance No! 1862 and the Rules and Regulations of_ the San Joaquin Local , HeaitF� <br /> :District. <br /> EXACT STREET ADDRESS <br /> Owner's" F� CITY/TOWN. <br /> Name <br /> Address . <br /> Phone <br /> Contractor's Name City <br /> License Ahone_ <br /> I5 CERTIfiICATE OF WORKt4APJ'S:�CO";PENSA7IOPl INSURANCE N FILE WITH SJLHD? YES <br /> TYPE OF WORK (Check) : NEW WELL L DEEPEN ( RECONDITION DESTRT <br /> 0 <br /> WELL-' CHLORINATION WELL ABANDONMENT [ OTHER R PUMP ,INSTALLATION 0 PUMP REPAIR(] PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK .L SEWER LINES 7., PIT PRIVY —� <br /> SEWAGE DISPOSAL FIELD � CESSPO L/SEEP�IGE PIT OTHER <br /> PROPERTY LINV,0-!PRIVATE DOMESTIC WELD pUBLI� DOMESTIC WELL <br /> i ` INTENDED USE TYPE OF WELL <br /> Industria CONSTRUCTION SpECIFICAT <br /> ' _ Cable Tool Dia, of Wel T V IONS <br /> f _DZA <br /> omestic/private —Drilled ation <br /> omestic/publici riven_ <br /> Dia. of Well Casing <br /> Irrigation D Gauge of Casing , <br /> - ravel 'Pack t `Depth of Grout Sea <br /> ` Cathodic Protection Rotary T <br /> _,._Disposal ! Type of Grout _ <br /> L_._�eophysical Other Information <br /> AA <br /> Surface Seal Insta ed <br /> PUMP INSTALLATION: Contractor <br /> e °� Type of Pump <br /> PUMP REPLACEMENT: ,: . <br /> Q State_ Work `Done �., . <br /> PUMP REPAIR: <br /> ; i0state Work Done <br /> DESTRUCTION OF: WELL: Well Diameter �_ d <br /> DescFi'be#Mate ria an Proce ure Approximate Depth <br /> I herebyr certify that �I'have' prepared this application and that the work will � <br /> with San Joaquin County Ordinances , -State Laws , and Rules and Regulations- oftheSan�Joaquin�Local'e` <br /> Hearth District: <br />