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SAN JOAQUIN.LOCAL HEALTH DISTRICT <br /> FOL,pFFICE USE: 3601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PER'MTT Permit No. J <br /> Date issued 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM PATE ISSUED <br /> {Complete In Triplicate) ril <br /> Application is hereby made to !.the San Joaquin <br /> Loapplicationaalth nistrict ra permit t <br /> made incompliancewithnstruc San Joaquin, <br /> and/or .install the work hereir_' described. <br /> County Ordihance�No. 1862 and' the Rules.and Regulations of the San Joaquin 'Local Health District. <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION � _ _ <br /> I Phone <br /> Owner's Name92 ilea <br /> City I 4A-t <br /> Address <br /> -License-~#v Phone -3 %a S" <br /> Contractor's Name �._ <br /> TYPE OF WORK (Check): NEW WELL '/'T, uEEPEN �,/7 RECONDITION �T DESTRUCTION JT <br /> PUMP INSTALLATION /� Yom' REPAIR /� PUMP REPLACEMENT I�T <br /> E other <br /> , PT PRIVY <br />`DISTANCE -TOT-NE ST: SEPTIC' TANK SEWER LINES _ , �1 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SREPAGE PIT _ <br /> OTHER <br /> 4PROPERTY LINE - PRIVATE IDOMESTIC WELL= <br /> PUBLIC-DOMEST-IC--WEL- <br /> INTENDED USE TYPE OF WELL „CONSTRUCTION 5PECIFICATIONS y , <br /> ab3e Tool Dia. of Well Excavation.. <br /> Industrial Dia. of 'Jell Whig <br /> omestic/private Drilled ; ,, _ t <br /> omestic/ ublic r~ Driven Gauge ;ofrCasing, f <br /> p C <br /> Irrigation _ Gravel Pack Depth4of-Grout Seal: -� $ <br /> Type of Grout <br /> Cathodic Protection Rotary 0 hex Information <br /> Disposal Other „_A%ij:co <br /> Geophysics] Surface Seal Installed 'B <br /> Contractor '��' H.P. <br /> PUMP INSTALLATION:' <br /> Type. of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> # e - � 1 <br /> pt. -� /,/_ State--Woxk n . <br /> Approximate Depth _ <br /> DESTRUCTION OF WELL: Well,{Diameter <br /> Describe Material ander^�ocedure„ --- -� <br /> ...-t <br /> I hereb a zee-.to comply with all laws and regulations of the SasCruction.LoWrict <br /> ithi.naFIFTEEN tDAYS <br /> Y B <br /> '} and the State of California pertaining to or regulating well con - <br /> after completion of my work on a new well, I will fuxneshuttiinhe Sathe�wellin�use..cal H�The habove District a <br /> WELL DRILLERS REPORT of the well and notify them before p g <br /> jinformaCion is true Co the best-of- my.knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A F AL IN-SPECTMg. TITLE <br /> SIGNED {DRAW PLOT PLAN ON REVERSE SIDE ~ <br /> FOR DEPARTMENT USE ONLY <br /> . PHASE ,�} DATE <br /> APPLICATTON' ACCEPTED BY . V} <br /> ADDITIONAL COMMENTS: ----.--_='PH�LSEYIII FINAL INSPECTION <br /> 5 PHA5E'I yGROUT”INSPE N IPISPRCTION BT, <br /> DATE L -1 <br /> INSPECTION BY f DATE <br /> r^ <br /> -VA - - <br />