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SAN JOAQUIN LOCAL HEALTH. DISTRICT �� 7& <br /> FOF OFFICE',USE':' 1601 E. Hazelton Ave. , Stockton, Calif.---- <br /> Telephone: <br /> alif. — " <br /> Tele hone: <br /> p (209) + 466-6781 <br />"k APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.�7-f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued27 <br /> (Complete In Triplicate) <br /> Aplplication is hereb made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This a nmpliance with San Joaquin <br /> County Ordi once.l�0...-1862 and,-theYRules and io s f he SDeal Health District. <br /> JOB ADDRESS/LOCATION PL N JrAE AYMd CENSUS TRACT <br /> Owner's Name C� LC� -C��s a Phone / 46 vd <br /> Address �� Gc-�p City <br /> Contractor's Name License ��� /.2!`3- Phone 0_-2_',_,7Pj>2 <br /> 2 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/—/ RECONDITION /_% DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY \ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �? <br /> Industrial Cable Tool Dia. of Well Excavation r% - <br /> Domestic/private 4—Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout1f <br /> Disposal Other' Other Information <br /> Geophysical'' Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Z <br /> Type of Pump- Y H.P. <br /> PUMP REPLACEMENT: / / State Work Done , <br /> PUMP .REPAIR; / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter �_ A i <br /> pproximate Depth - ,! <br /> Describe Material and -Procedure '- <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <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 -and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO XVUJING D A FINAL INSPECTION. <br /> SIGNED TITLEZ' <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br />' PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: d <br /> PHASE II GROUT INSPECTION ISE II/F AL INSPECT ON <br /> INSPECTION BY DATE /� INSPECTION BDATE <br /> Ole <br /> F 14 1179 A 117.7 `. <br />