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.mss <br /> µ� ✓ SAN JOAQUIN .LOCAL HEALTH DISTRICT I <br /> 8';OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: ' (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDF -Date Issued <br /> (Complete In Triplicate) <br /> o construct <br /> Application is hereby made to the San Joaquin Loc al Health District for a peitetwith San Joaquin <br /> pp application is made in complianc <br /> and/or install the work herein described.. This app <br /> County Ordinance No. 1852 and the Rules and -Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION SS" lid CENSUS TRACT .- <br /> r^ Phone <br /> Owner's Name <br /> Address - .. <br /> City <br /> Contractor's Name License # 2h—,s'7JP�onel <br /> ---w-- <br /> TYPI: OF WORK (Check): NEW WELL t�" DEEPEN I �—RECONDI�T16N'-/_I TRUCTION <br /> E PUMP INSTALLATION /——PUMP REPAIR /7 PUMP REPLACEMENT jL <br /> Other <br /> t s <br /> DISTANCE TO NEAREST: SEPTIC TANK�� t SEWER LINES #- PIT PRIVY ! i <br /> SEWAGEDISPOSAL-FIELD _ CESSPOOL/SEEPAGE PIT s OTHER <br /> PROPERTY LINE - ,PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> ' INTENDED USE TYPEOF WELL CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavation if d <br /> v I dustrial ;r <br /> Domestic/private .,- Drilled Dia. of Well Casing <br /> Domestic/public , r -_ Geuge of�Casing <br /> Drij <br /> - �Irrigatioa`9` ^:��Gravel Pack { . Depth of Grout Seal � 3 <br /> Cathodic Protection f�Rotary Type of-Grout . jj;tg AV, <br /> Other Other Information _ <br /> Disposal i r1' lGeophyei.cal Surface Seal Installed S <br /> PL;W NSTALLATION: Contractor C h D . r, H.P.; .� <br /> ► Type of Pump S <br /> PUMP REPLACEMENT• / / IState _ -- - - <br /> S a„<.. � <br /> _,/ State-Work-Done"_. <br /> PUMP `.REPAIR: f <br /> Approxiii1te Depth <br /> EWell Diameter <br /> STRUCTION OF WELL: <br /> Describe Material and Procedure <br /> l 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'GROT3T .INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> TITLE <br /> SIGNED <br /> r DRAW PLOT PLAN ON REVERSE SIDE <br /> I FOR PEPAMMENT USE ONLY a <br /> I PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: HAS I F AL NSPECT ON <br /> PEASE 17GR0 INSPECTION <br /> .E ION BY / DATE _ INSPECTION BY DATA <br /> INSP <br /> urad.. a'uL d�rl/ �Jy8ax ,�e a �Ce pzclk r�-c� t vevw o4,_m o a f J eC 1-7 4 2M Gr1e1,1E H 1426 Rev. 1-7Fc., <br /> Qsa� G/P.�� XX2 <br />