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I SAN JOAQUIN LOCAL HEALTH DISTRICTCalif- <br /> USE, <br /> f. <br /> FFUSE: <br /> OICE Y, _ <br /> 1601 E. Hazelton Ave. , Stockton, <br /> Telephone: (209) 466--6781 permit No. <br /> 7� <br /> n APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> { Date Issued /- -� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED, <br /> (Complete In• Triplicate) it <br /> s hereby made to the San Joaquin Local Health District for <br /> congliancetwithnSan Joaquii <br /> .ppstruct <br /> lication i Y application is ma <br /> `and/or install the work herein described. This app <br /> County Ordinance No. 1862 and the Rules .and Regulations of the San Joaquin Local Health District. <br /> e 1, Q .�,°� � CENSUS TRACT . <br /> ':JOB ADDRESS/LOCATION,,J <br /> �1 Phone <br /> Owner's Name <br /> City . <br /> Address - . +�, <br /> License # Phones <br /> Contractor' s Name <br /> � OF WORK Check) : NEW''iWELL / DEEPEN / RECONDITION DESTRUCTION /� ,p <br /> �:'1YPE ( <br /> -wl PUMP 1NSTALLATION /1P ' REPAIR / / PSH' REPLACEMENT / I <br /> f <br /> Other-- <br /> SEWER LINES PIT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC TANK _ OTHER <br /> � SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> PUBLIC DOMESTIC WELL -� <br /> PROPERTY LINE - 1'12IVATE DOMESTIC WELL CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL - <br /> Cable Taal Dia. of Well Excavation .. <br /> Industrial Dia. of Well Casing, a ' <br /> Domestic/private Dulled <br /> Gauge of Casing <br /> Domestic/public <br /> Driven <br /> gs <br /> Irrigation�.r G " Gravel Pack Depth of Grout Seal <br /> T e of Grout ., <br /> Cathodic Protection Rotary her Information.� <br /> Disposal <br /> Geophysical Other ` Surface Seal Installed B <br /> h .. - <br /> F <br /> PUMP INSTALLATION: Coutractor.�A 12,e'r H.P. <br /> 4 Type of Pump C- <br /> t=Jl # '.^ <br /> PUMP REPLACEMENT: / `/ State Work Done <br /> PUMP REPAIR• ' ' -4- <br /> /.- State-:Work Done <br /> DES•TRUCT.ION;"OF WELL: Well Diameter., <br /> Approximate Depth <br /> Describe Material and Procedure <br /> i I hereby agree to comply;with all laws and regulations of the San J-oaquin Local Health District <br /> and the State of California pertainin 'to or regulating well -construction. Within FIFTEEN DAY' <br /> ellI will furnish <br /> after completion of my work on a new w , the San Joaquin Local Health Distric <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-rand»beli.e-f I-WILL CALL FOR A GROUT INSPECTIOt <br /> PRIOR TO GROU G AND A FINAL PECTION. 84 TITLE `� _ •� <br /> 4 SIGNED X RAW OT PLAN ON REVERSE SIDE) <br /> (f I <br /> t <br /> k FOR DEPARTMENT USE ONLY <br /> F PHASE I DATE <br /> t APPLICATION ACCEPTED BY a, <br /> ADDITIONAL COMMENTS: J PHASE III/FINAL INSPECTION <br /> PHASE II O T INSPECTION INSPECTION BY DATE *. 7 ' _ <br /> INSPECTION BY DATE <br /> 2M <br /> ,i,,)A uo,r_ . 1--74 <br /> -- - <br />