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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE, 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: ' (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �, � <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Applicatistruct <br /> on is hereby made to: Saaquhisin oapplica'tianDistmade inrict rcompliancea permit twithnSan Joaquin <br /> and/or install the work herein described. <br /> County Ordinance No. 1862 and` he Rules and. Regulations of the San Joaquin Local Health District. <br /> ENSUS TRACT <br /> JOB ADDRESS/LOCATION n Ko <br /> ,3:,• j v� - Phone <br /> Owner's Name �� <br /> Adloo <br /> City rVLC <br /> Address v <br /> License # ',/g 7xjPhone C,4 7, <br /> Contractor's Name `` <br /> RECONDITION / DESTRUCTION /_7 <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEP / pip REPLACEMENT I�T <br /> PUMP INSTALLATIO / PUMP REPAIR/ / <br /> Other, / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVYCESSPOOL/SEEPAGE <br /> PIT—OTHER <br /> SEWAGE DISPOSAL FIELD PUBLIC DOMESTIC WELL <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE <br /> Industrial Cable Tool Dia. of TYPE OF WELL <br /> Well Excavation <br /> Domestic/private " Drilled Dia. of Well Casing. <br /> . --�- s Driven Gauge of Casing <br /> Domestic/public De th of Grout Seal <br /> Irrigation Gravel Pack F <br /> Cathodic Protection Rotary Type of Grout <br /> ' Other �� Other Information <br /> Disposal Surface Seal Installed By: . <br /> \(` <br /> Geophysical <br /> PUMP INSTALLATION: Contractor H'P, ✓ <br /> Type of Pump 0----------- . <br /> _4 <br /> f PUMP REPLACEMENT: / / I State Work Done <br /> PUMP �. tate Work Done <br /> � I .Fs � <br /> � �: - <br /> DESTRUCTION •OF WELL: <br /> l Diameter Approximate Depth <br /> Describe Material and Procedure <br /> x . .r <br /> f.,<.. <br /> istrict <br /> cal elth <br /> I I hereby agree to. comply with all laws and regulations oW�ii�'construction.JoaquinLoWithinaFIFTEEN DAYS <br /> E and the State of California pertfning to or regulating Dist <br /> after completion of my work on a`*new well, I lbeforesputtingatheowellninouse•Health <br /> furnih the The aboverict <br /> WELL DRILLERS REPORT of the well and notify them <br /> information is true-- 4 the bests�of my k wled e and belief. I WILL CALL FOR A'GROUT INSPECTION <br /> PRIOR TO GR UTINsAND A' FINAL TTySPE IO . TITLE . <br /> SIGNED •' ( W-P OT LAN ON VERSE SIDE) <br /> f - <br /> ? FOR DEPARTMENT USE ONLY <br /> PHASE I 'DATE — <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION. <br /> PHASE II GROt3T INSPECTION INSPECTION BY /'_ _ <br /> INSPECTION BY DATE <br /> 1177 _ <br /> , <br /> IT 1 I.•]G ID 1_7A _ _ <br />