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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0 *OF ICE USE: 1601 E. Hazelton.Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6?81 8 Ia <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> Date Issued 6 ..' <br /> THIS PERMIT EXPIRES 1 YEAR F E ISSUED - . <br /> (Complete In. TripROMs e) <br />' Application is Hereby made to the San Joaquin Local <br /> istmade inrict rco pliancea permit twithnSan Joaquin <br /> and/or install the work herein described. pp <br />':' County Ordinance No. x:862 and the Rules and 'Regulations of the San Joaquin Local Health District. <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> f Phone ' <br /> Owner's Name A <br /> jAgo <br /> � Cita <br /> ,Address <br /> License # '1 :- hone . <br /> 1i. Contractor's Name <br /> OF WORK Check) : NEW WELL /_7 DEEPEN "/ wRECONDITION �T DESTRUCTIONLACEMEN�/T <br /> TYPE ( PUMP INSTALLATION �/ PUMP.,REPAIR /� PUMP -- <br /> Other l_7 <br /> PIT PRIVY _ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES OTHER U <br /> SEWAGE DISPOSAL CESSPOOL/SEEPAGE PIT FIELD <br /> �- PROPERTY LINE - PRIVATEDOMESTIC WELL PUBLIC.DOMESTIC WELL �1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION.SPECIFICATIONS <br /> ' Industrial i Cable Tool Dia, of Well Excavation G <br /> Drilled Dia. -of Well Casing <br /> x Domestic/PrivaCe i - Driven Gauge of Casing <br /> Domestic/public <br /> Irrigation i _ Gravel Pack- Depth of Grout Seal <br /> T e of Grout <br /> Cathodic Protection "I -Rotary 3'p <br /> ;► Other Other Information <br /> Disposal ��" Surface Seal Ihstalled 'B <br /> �Geophysical <br /> c <br /> PUMP INSTALLATION: Contractor � ' H.P. r <br /> Type -of Pump _ . <br /> _ State Work Done <br /> PUMP / <br /> PUMP ,REPAIR: / / .3 State Work Done <br /> �. Approximate Depth _ <br /> € I?ESTRUCTION OF..,WELL: Weld Diameter � <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and reguiatitin of the San J0 Lo <br /> wellconstruction. Within cal aDistrictlth <br /> FIFTEEN DAYS <br /> and the State .of California pertaining to or willregufg <br /> � after completion of my work on a new well, I will furnish the San Joaquin Local Health District + <br /> SWELL DRILLERS REPORT of the well .and notify them ndfore belie£tting the -welLin..use_l WILL CALL tiFOR A GROUTeINSPECTION <br /> above <br /> [ information is true to the�best-a 'f'� <br /> PRIOR TO GROUTING AND A FINAL INS TYLE <br /> SIGNED s!./. , <br /> w — � (D W PIAT _PLAN ON R,?4VERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ( ADDITIONAL COMMENTS: PHASE III FINAL INSPECTION <br /> PHASE II GROUT INSPECTION DATE <br /> INSPECTION BY _�- DATE _ INSPECTION BY <br /> r' <br />