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I � <br /> SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> il } Telephone: ' (209) 466-6781 7 R� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit N) -2 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -d6-� <br /> (Complete In Triplicate)- <br /> Appl.icat'ian is here made -t�o the San Joaquin Local Health District fora permit to construct <br /> and/or install, the work-1,1her6 n described. This application is made in- compliance with San Joaquin' <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION . CENSUS TRACT <br /> AU <br /> Owners Name Phone <br /> C4 r <br /> Address City <br /> Contractor's Name jAlrQ License ,j � I 'Phone ' \ <br /> I <br /> : NEW WELL J DEEPEN / / RECONDITION /_/ DES'T,RUCTION /� <br /> TYPE OF WORK (Check _ <br /> ) <br /> PUMP -INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ,L SEWER LINES �wPIT PRIVY/ Q_ <br /> SEWAGE DISPOSAL FAELD CESSPOOL/SEEPAGE PIT OTHER <br /> k PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE h :TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ! Cable Tool Dia. of Well Excavation <br /> Domestic/private ie 1---y Drilled Dia, of Well Casing <br /> Domestic/public "1 Driven Gauge of Casing <br /> Irrigationii Gravel Pack Depth of Grout Seal <br /> Cathodic Protecti.!on {Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical !j Surface Seal Installed By::: <br /> ' PUMP INSTALLATION: :[Contractor <br /> �Typejof Pump H.P. <br /> i <br /> PUMP REPLACEMENT._::::.s !�/ / ' State Work Done <br /> PUMP_KREEPj�AIR: ! State Work Done <br /> DESAilCT 0 OF WELL: Wel 1 Diameter _ _ ,Approximate Dep ~ <br /> a <br /> 1GtJD'escrib� M t`eri=a' nd I'rocecl+ire <br /> ��lrG ��� - a <br /> I hereby agree�� to ccomply i 1? a7 ws�and re'g at ons of t e San"To u` W alr'He' th�Di sui t <br /> and the Stae--Vf California pertaining to or regulating well"construction. Within FIFTEEN DAYS <br /> after completion of my1work' 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 tolthe{best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> �rRIOR TO GR UTI G A F NAL INSPECTION. TITLE <br /> SIGNED,- <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FO DEPARTMENT USE ONLY <br /> PHASE eA/ 7 <br /> I ��. <br /> APPLICATION ACCEPTED BY DATE <br /> { ADDITIONAL COMMENTS: IM <br /> PHASE I , ROUT INSPECTION PHASE /FIN INSPECTIO <br /> INSPECTION BY ATE G INSPECTION' BY DATE�� 2 <br /> F H IA?A R7,17 , <br />