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SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> FOR..�OFFICE USE: ; <br /> _ Telephone: (209) 466-67-81 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3 <br /> . - Date Issued <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED � -- <br /> (Complete In Triplicate) s <br /> Application is hereby made tothe San Joaquin�soaalHealthlicatio nistmade infor <br /> compliancetwith SanuJoaquin' <br /> l <br /> and/or install the work herein described. Th PP <br /> County Ordinance No. 1862 and the Rules and Regulations Of-'the�San Joaquin Local Health District. <br /> l7' A k f_ CENSUS TRACT <br /> JOB ADDRESS/LOCATION vrfc <br /> Phone .: <br /> Owner's Name <br /> Address <br /> 5f- City <br /> '� ''Phone c� <br /> License 4��� � - i <br /> Contractor's Name <br /> C <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / / RECONDITIQN I / DESTRUCTION I�T <br /> PUMP INSTALLATION <br /> / PUMP REPAIR' / PUMP REPLACEMENT �'-T . <br /> Other. <br /> DISTANCE TO NEAREST: SEPTIC TANK f SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT f,€ �"OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> ------INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> i <br /> Cable Tool�'"'"'�"�-D3a. of'We11 Ex n . <br /> ! Indus trial <br /> Domestic/private Drilled Dia. of Well Cas!-vati.0 <br /> ng <br /> Driven Gauge of Casing � <br /> Domestic/public <br /> Irrigation � Gravel Pack Depth of Grout Sealy <br /> „ Y Rotar Type of Grout t'K' <br /> Cathodic Protection <br /> ' Other Other Informati-,__ , <br /> } Disposal , - Surf ate Seal Installed B <br /> Geophysical <br /> POW INSTALLATION: Contractor H.P. f- : r <br /> .. ' <br /> Type of Pump <br /> t <br /> PUMP REPLACEMENT• / / State Work Done one <br /> 1 PUMP 'REPAIR: /�/ State Work Done <br /> << Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter - <br /> 1 ��^• Describe Material and Procedure L � r <br /> i <br /> I hereby agree to comply witrict <br /> h all laws and <br /> welletonstruction.LoWithinaFIFTEENDistDAYS <br /> and the State of California pertaining g <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <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 FORA GROUT�INSPECTION <br /> PRIOR TO GROUTING A NAL IN Y ECTXN, TITLE •. _ �_ <br /> SIGNED f <br /> � '� 's(DRAW PLOT PLAN ON REVERSE SIDE) <br /> A FOR DEPART T USE ONLY <br /> _ PHASE I �1 _ _ T13ATE.—g- A <br /> ;:APPLICATION-ACCEPTED,�BY- <br /> ADDITIONALC7COMMENTS: / 74 � �`'� _ PHASE III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTI N INSPECTION BY DATE <br /> INSPECTION BY t DATE <br /> 1177 _ <br /> ,. y/.nL 13om.. �r7L. <br />