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SAN JOAQUIN LOCAL HEALTH DISTRICT C� } <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> FOR-OFFICE USE• <br /> Telephone: (Z09) 466-6781 Permit No. T i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT ; <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made toi the San Joaqu his°aallication istmade inrco pliancea permittwithnSanuJoaquin: <br /> and/or install the work herein described. PP <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. � <br /> ��� �-� �t�/l1 ��-" cENsus TRACT <br /> JOB ADDRESS/LOCATION ��J�,. <br /> I5, 1A <br /> ? � r Phone <br /> Owner's Name r/� - � 1 J <br /> i Cit G /4 /l <br /> Address $ <br /> C � 1 7 y <br /> �� LicensePhone('l��� <br /> Contractor's Name C .'� � <br /> ;E <br /> • NEW WELL / DEEPEN '/ I RECONDITION I�I DESTRUCTION NTT <br /> TYPE OF WORK {Check) . <br /> PUMP INSTALLATION / % PUMP REPAIR; .I ' FUME <br /> REPLACEMENT <br /> I;T <br /> Other <br /> PIT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES OTHER <br /> f SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> f -PUBLIC-*DOMESTIC WELL <br /> f PROPERTY LINE - PRIVATE DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS \ <br /> Cable Tool Dia. of Well Excavation <br /> industrial ,� Dia. of Well Casin <br /> � Drilled "._ g <br /> Domestic/private — "- ` <br /> --� Driven Gauge of Casing <br /> Domestic/public Depth of Grout Seal <br /> Irrigation 6V <br /> Gravel Pack P _ <br /> Type of Grout C� <br /> Cathodic Protection Rotary <br /> �R KOther .Information <br /> Other <br /> E —Disposal - Surface Seal Installed B <br /> Geophysical <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: - �/ , - State Work Done i <br /> PUMP .REPAIRi State Work Done <br /> ►a , <br /> Approximate Depth , <br /> DESTRUCTION OF WELL: Well eter <br /> DescribemMatei;ial', and Procedure ` <br /> to complywith all laws and regulations of the San Joaquin Local Health District <br /> I hereby agree Within <br /> AYS <br /> and the State of California�pextaining to or re111fuxngshethecSantJoaquin•Local HealthTDistEEN riat' <br /> ` after completion of my work on a new well, I wi <br /> WELL DRILLERS REPORT of the well and notifythem <br /> ndfbelief. I WILL CALL FOR Aore putting the well in eGROUTeINSPEGTION <br /> information--is-true- to the:best of my g <br /> PRIOR TO G OUTING AND A..FINAL NSP . CTION. TITLE 0 <br /> SIGNED i {DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � DATE II � �� 4 •— <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: C PHASE III/FINAL INSPECTION ' _ <br /> PHASE II GROUT INSPECTION DATE <br /> IN <br /> :.DATE... -' - INSPECTION. BY . <br /> INSPECTION BY�� - -` - <br /> 1177 <br /> 2M <br /> 7L <br />