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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, r/ <br /> FOR OFFICE USE: Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT permit No. <br /> � Date issued <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDi <br /> (Complete In Triplicate) ermit to construct <br /> uinj <br /> Application is hereby made to� the San Joaquin LocalHealthlicatio Histrict for a made in co pliance ealthwith SDistrian ct. <br /> and/or install the work herein described. This app <br /> County Ordinance No. 1862 and; the Rules and Regulations Of the San Joaquin Local H <br /> LtAy���- !�-� CENSUS TRACT <br /> JOB ADDRESS/LOCATION I.j ti=� <br /> Phone L 3-5� <br /> Owner's Name <br /> R <br /> JA <br /> �,,yy = " City <br /> 40. <br /> Address 0 .... <br /> License # S s 75�Phone 5------of �4' <br /> Contractor's Name tj+ <br /> ' DESTRUCTION /-7 <br /> 4 DEEPEN / / RECONDITION I I <br /> TYPE OF WORK (Check) : NEW WELL / / Pip REPAIR /� ° pip REPLACEMENT /� <br /> PUMP ELL <br /> � . � <br /> �,E.•v� f� 0 the i / I <br /> ,,�•�` SEWER LINES PIT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC TANK CESSPOOL/SEEPAGE PIT OTHER <br /> SEWAGE DISPOSAL FIELD PUBLIC DOMESTIC WELL <br /> PROPERTY <br /> LINE - PRIVATE DQMESTIC WELL CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE -TYPE OF WELL • <br /> G a ,. +Cable�Tool Dia.. of'Well' Excavation <br /> Industria] Drilled Dia. of Well Casing <br /> Domestic/private <br /> Driven Gauge of Casing <br /> Domestic/public Depth of Grout Seal <br /> Irrigation Gravel Pack P - <br /> Rotary Type of Grout <br /> Cathodic Protection Other _ Other Information <br /> f Disposal Surface Seal Installed By. <br /> Geophysical <br /> PUMP INSTALLATION: Contractor H.P. C� <br /> Type of Pump <br /> r <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / State Work Done <br /> Approximate Depth <br /> f DESTRUCTION OF WELL: Well Diameter <br /> i Describe Material and Procedure <br /> ulations of the San Joaquin Local Health District <br /> I hereby agree to comply with all laws and reg well,-construction. <br /> Within. FIFTEEI3 DAYS <br /> and the State of California pertaining to or regulating <br /> iter completion of my work on a new well, I will furnish the San Joaquin Local Health District <br /> a <br /> above <br /> WELL DRILLERS REPORT of the well and notified emandfbelief. I WILL CALL FOR AeGROUT eINSPECTION, <br /> information is true to the-best of my know ..g <br /> � PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> TITLE <br /> SIGNED t (DRAW PLOT PLAN ON REVERSE SIDE} <br /> i LY <br /> USE ON <br /> FOR DEPARTMENT - <br /> plHASE I DATE f <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: p INAL SPECTI N <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE <br /> INSPECTION BY *: DATE <br /> ._ 6a(� <br /> ,_-7). - <br />