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SAN JOAQUIN LOCAL HEALTH DISTRICT R <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466 -6781 Permit No. � !;5 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> I , <br /> Issued <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date ay 7 <br /> (Complete In Triplicate) <br /> Application is hereby made t6 the San Joaquin Local Health District for a permit to construct <br /> and/or <br /> install the work herein described. This application is made in compliance with SDistrct3n <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> CENSUS TRACT k <br /> JOB ADDRESS/LOCATION . <br /> ' .. .1 Phone <br /> Owner's Name ' <br /> City <br /> Address Q ' , <br /> ,, f } '� License �� Phone <br /> Contractor's Name PAWS <br /> TYPE OF WORK (Check) : NEW WELL .r D_EEPEN,:/�/ RECONDITION / DESTRUCTION I`�T <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT I <br /> Other l/ 1 �s O <br /> DISTANCE TO NEAREST: SEPTIC-TANK 1 SEWER LINES PIT�,PRIVY -� <br /> L/'S•EEP•_AGE'`;:PIT OTHER <br /> �DI . <br /> SEWAGE SPOCESSPOO <br /> SAL„FILD ,. <br /> s \PROPERTY LINE -,PRIVATE DOMESTIC WELD PYLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL " CONSTRUCTION SPECIFICATIONS <br /> ?- ,F �— <br /> Industrial Cabre Tod'1( Dia. of-x.Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domesti.e'/.public I Driven Gauge of Casing <br /> Irrigation t Gravel Pack Depth of Grout Seal <br /> Cad odic Protection Rotary Type of Grout <br /> ,D 1 <br /> other <br /> Other Information <br /> Geophysical t , Surface Seal Installed B { <br /> - a <br /> PUMP INSTALLATION: Contracto, °¢'S '"° H.P. <br /> Type hof Pip <br /> PUMP REPLACEMENT: State Work Done <br /> - - <br /> PUMP-.REPAIR• / / StatesfWork Done <br /> lo <br /> Approximate Depth <br /> DESTRUCTION OF WELL: WellfiDiameter .: <br /> Describe Material and–Proced:ii're <br /> i laws and regulations of the San Joaquin Local Health District <br /> f I hereby agree to comply with all <br /> and the State of Cali,forriia pertain gY,to or, tregulaing weilcostxuction.� WithinFIFTENDAYS <br /> after completion of my work on anew well, I will furnish the Saheowellnlnouse.HeThehaboveDistrict a <br /> WELL DRILLERS REPORT of the well an notify them before putting <br /> ` information is true to the-best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING D A FINAL INSPECTION. TITLE <br /> SIGNED <br /> ,(DRAW,�PL-OT(`PLAN ON REVERSE SIDE) <br /> F'OR'DEPARTMENT USE ONLY <br /> PHASE I <br /> DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: pINAL NSPECTION - <br /> PHASE II GROUT INSPECTION 1()NJ, �j 1, SE ATE S- � <br /> INSPECTION BY M fir+ DATE,)f; 1 .Y;`� '. : �� INSPECTION BY �� ` <br />