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SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> Stockton, Calif. <br /> �r'FICE USE: 1601 E. Hazelton Ave <br /> Telephone: (209) 466-6781 <br /> �. Permit No' <br /> i APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> THIS: PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued'- <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin <br /> rict f <br /> isLocal lHealth <br /> CationDistmade inrcompliance a permit twith San Joaquin <br /> and/or install the work herein described. Th pp <br /> Count No. 1862 and the Rules and Regulations of the San Joaquin Local. Health District. <br /> Y Ordinance. � k ' <br /> CENSUS TRACT { <br /> JOB ADDRESS/LOCATION �-Z <br /> Phone Z3 - i <br /> Owner's Name <br /> t✓/L� City rr.4�",--�c/�-' <br /> Address rV <br /> License 316y3 hone9 <br /> Contractor's'Name G <br /> WORK CW WELL / / DEEPEN /_IUMP RECONDITION_ / DESTRUCTION- / <br /> TYPE OF WO (Check ) : NEW PREPAIR-/ / PUMP REPLACEMENT /� <br /> PUMP INSTALALLATION Cf� ` <br /> - Other, / / <br /> SEWER LINES PIT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC TANK CESSPOOL/SEEPAGE PIT OTHER <br /> SEWAGE,DISPOSAL FIELD PUBLIC DOMESTIC WELL <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL <br /> . CONSTRUCTION SPECIFICATIONS � <br /> } INTENDED USE TYPE OF WELL Cable 'fool Dia. of Well Excavation! <br /> T <br /> Industrial Dia. of Well Casing <br /> Drilled `1 <br /> t' Domestic/private Driven Gauge of Casing <br /> Domestic/public Gravel Pack Depth of Grout Seal <br /> Irrigation <br /> Rotary Type of Grout <br /> Cathodic Protection Other Other Information <br /> Disposal <br /> _ Surface Seal.- <br /> Geophysical Installed B : <br /> fFM f <br /> I PUMP INSTALLATION: Contractor C_ H.P. Sp - <br /> TYpp of Pump <br /> . PUMP REPLACEMENT: / / iState Work Done <br /> e Work Done <br /> PUMP ,REPAIR: + "Statj � <br /> r x Approximate Depth , <br /> DESTRUCTION OF WELL: Well,. Diameter and Procedure <br /> Describe Material <br /> i F <br /> tion <br /> San Joaquin <br /> cal <br /> lth <br /> J I hereby agree to comply with all laws and regelulating�welleconstruction.LpWithin aFIFTEEN tDAYS <br /> and the State of California pertaining to or g <br /> kafter completion of my work on a new well, I willbfurnisputtingthe athe owell- in,use.HeThe h bower c <br /> Wefore <br /> ELLDRILLERS REPORT of' the well and notify <br /> the <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> 1PRIOR TO GROUTING AND FINAL INSPECTION. 'TITLE ��",•C/L- <br /> SIGNED (DRAW PLOT PLAN ON REVERSE SIDE) <br /> F DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> :Ay-PLICATION ACCEPTED BY `� <br /> ADDITIONAL COMMENTS: PHA E /FIN INSPECTION <br /> i PHASE 11 GROUT INSPECTION INSPECTION BY DATE x.- 17 -� <br /> ' INSPECTION BY DATE <br /> . , . 1177 _ ', 2M <br /> { <br />