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to p � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: l/ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> •, Telephone: (209) 466-6781 Permit No. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> THIS PERMIT EXPIRES 1. YEAR FROM DATE ISSUED Date Issued <br /> I .(Complete In Triplicate) <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 s neJoa uinin pLocaleHealthSan District. <br /> County Ordinance No. 1862 and the Rules and Regulations of the q <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> Phone <br /> Owner's Name d <br /> / City ' <br /> Address U Avl � <br /> 76 <br /> License �� Cj �Phone <br /> Contractor's Name <br /> TYPE OF WORK (Check) :' ,NEW WELL / / DEEPEN /�/ RECONDITION / P DESTRUCTION <br /> "PUMP INSTALLATION / / PUMP REPAIR / UMP -- <br /> Other <br /> k DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY. <br /> i. SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> t PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL `n <br /> INTENDED USE a TYPE OF WELL CONSTRUCTION SPECIFICATIONS v) <br /> Industrial, Cable Tool. Dia. of Well Excavation V� <br /> �^ Domestic-/private.,, <br /> Drilled Dia. of Well Casing <br /> Domestic/public <br /> Driven Gauge of Casing <br /> t Irrigation _ Gravel Pack Depth of Grout Seal <br /> RotaryTYPe of Grout , <br /> ( Cathodic Protection Other information <br /> Disposal Other <br /> Geophysical Seal Installed By- <br /> Surface <br /> PUMP INSTALLATION: Contractor H.P. <br /> i f <br /> Type of 'Pump <br /> PUMP REPLACEMENT: ;e.. / / State Work Done <br /> PUMP .REPAIR: /X/ <br /> State Work Donees ''°�'�` ` 00 <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well. Diameter <br /> Describe Material and Procedure <br /> I. hereby agree' to comply with all laws and regulation dwell'construche San tion.Local <br /> WithinHealth <br /> FIFTEENDistrict <br /> DAYS <br /> .and the State of California pertaining to or .regulat g .. <br /> ' well, I will furnish the San Joaquin <br /> after completion of my work on anew Local Health District <br /> WELL DRILLERS REPORT of the well and notify them before putting the- well in use.. The above <br /> information is true to the best of- my. knowledge a d .belief: I WILL CALL .FOR A GROUT INSPECTION <br /> PRIOR TO GROU ING AND 'A FINAL PECTION. TITLE /�1'• ;' <br /> SIGNED d <br /> (D l PL PLAN ON RP1TMV.5R5-,F. SIDE) <br /> DEPARTMENT USE ONLY <br /> PHASE I p � DATE 4 -k'� — <br /> APPLICATION ACCEPTED BY cG <br /> ADDITIONAL. COMMENTS: PHASE; II/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY <br /> INSPECTION BY DATE <br /> / <br /> 7.7 2M f <br /> u 1A9A 1) ­ 1-76 - <br />