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w_ USAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> 4 <br /> Fb��OFFICE USE: 1611 01 E. Hazelton Ave. , ,Stockton, Calif. _ <br /> 0� „lam Telephone: (209) /+66--6781 + <br /> APPLICto <br /> ATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued�! b <br /> (Complete In Triplicate) a permit <br /> Application is ct <br /> hereby made torhaquThisocal aPplHcation isin <br /> tmade for <br /> compliance twith nSan uJoaquin' <br /> and/or install the work herein described <br /> County Ordinance Na. 1862 and the Rules and Regulations of the San Joaquin Local Health District. + <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION 4 9 - <br /> 1 Phone �O <br /> Owner's Name <br /> City , <br /> Address US <br /> Contractor's Name <br /> G License ��� Phone 2- <br /> DESTRUCTION /~T <br />' Al.1S <br /> TYPE OF WORK (Check) :. NEW WELL *` DEEPEN / RECONDITION /� <br /> d� ' PUMP INSTALLATION / / PUMP REPAIR REPLACEMENT <br /> other--!j F <br /> t <br /> DISTANCE TO NEAREST: SEPTIC""TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGEI"DISPOSAL FIELD ,, '.� i CESSPOOL/SEEPAGE PTT ' OTHER <br /> PROPERTY.. LINE = PRIV'ATE bOME5TIC WELL PUBLIC ;DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCT-ION .SPECIFICATTQNS <br /> Industrial } Cable Tool Dia. of Well Excavation <br /> Drilled Dia. of Well Casing <br /> Domestic/private I `�"`Driven l Gauge of Casing <br /> i. Domestic/public = 'De th of Grout SeafdB <br /> Irrigation X <br /> Gr, P <br /> Type of Grout <br /> Cathodic Protection _ Rotary Other Information: <br /> Disposal Other — . 7 <br /> Geophysical Surface Seal Insta <br /> P <br /> M <br /> ` PUMP INSTALLATION: Contractor --. H.P. <br /> Type of Pump-� <br /> ( PUMP REPLACEMENT: / / State Work Done <br /> State Work Done �~ <br /> PUMP .REPAIR: �/ <br /> Approximate Depth ' <br /> DES-TRUCTION OF WELL: Well Diameter . - � <br /> Describe Material and ProcedureJoaquin§ <br /> cal <br /> lth <br /> I hereby agree to comply with all laws and reguSan <br /> lation Dwell'.construction.LoWithHnaFIFTEENtDAYS <br /> G- and the State of California pejo aining to or regulating <br /> after completion of my work on anew well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notifyeaheanedfb�ieftt I WILL C.ALLFOR Are puing the �7elllin useGROUTeINSPECTION <br /> information is true to tti°e bes of my knowl gem _ <br /> ;PRIOR TO GRO TI G J&D A FiNAL INSPECTION. TITLE <br /> SIGNED <br /> {DRAW PLOT PLAN QN REVERSE SI F <br /> FOR DEPARTMENT USE ONLY I <br /> PHASE I DATE - <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: �- PRASE III/FINAL, TNSPECTON. <br /> PHASE I OUT INSPECTION , y INSp1JCTI0N-BY - DATE--- <br /> INSPECTION BY "-,DATE ' <br /> F } <br /> 1/7.7 _ 2M <br /> u 1LIA vo.,- 1-74 <br />