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FO ;OFFCE::.USE: <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I I� 1601 E. Hazelton Ave. , Stockton, Calif-. . . ; <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WIELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 3 7�4i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATEISSUED <br /> - Date Issued <br /> A {Complete In Triplicate) <br /> Application ie- Her by made to the San Joaquin Local'Health District for a permit to construct <br /> fand/or install the work. herein described. This application ,ie made in compliance with San Joaquin <br /> County Ordinance .Nei. 1.852 and the Rules and Regulations of the' San Joaquin- Local Health District. <br /> j JOB 'ADDRESS/LOCATION i <br /> {} CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> `. Addre' ss k <br /> . City <br />` Contractor's Name , <br /> R - License # Phone , <br /> 4,y,. k - <br /> TYPE OF WORK (Check): NEW WELL � DEEPEN - - '� <br /> k" / RECpNDITION- L f- DESTRUCTION <br /> PUMP IN5T LATION /—/ PUBP REPAIR ,/-7 PUMP REPLACEMENT <br /> 3. Othet / % • <br /> �i <br /> DISTANCE TO NEAREST: SEPTIC TANK `.1r', _ 'SEWER LINES <br /> f SEWAGE DISPC-S FIELD - PIl" PRIVY <br /> # CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY.UTNE. - PRIVATE DOMESTIC WELL ' PUBLIC 'DOMESTIC WELL <br /> ` INTENDED-USE- i. TYPE OF-WELL <br /> \ <br /> Industrial CONSTRUCTION SPECIFICATIO S <br /> a' Cable Tool Dia. of Well ,Excavation <br /> =~Domestic/private ' <br /> ' Domestic) ublic I ° �`'y-~~- -,Drilled Dia., ofx;Well�a ng <br /> p Driven u <br /> :Gauge of Casing <br /> i Ir-riga -=--�- <br /> Gravel Pack Depth ,of Grot Seal <br /> !'Cathodic Protection <br /> Rotary �� Type of-,Grout <br /> 'Disposal Other, <br /> -'Geophysical `. Other Information . - <br /> " `w Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> - <br /> f �I f Type of Pump. <br /> H.P. i <br /> PUMP REPLACEMENT: State Work Done� ...... <br /> PUMP '—REPAIR:, <br /> E-7 State. Work Done' <br /> DESITRUCTION4 OF. WELL: -Weill .Diameter <br /> Approximate Depth _ r <br /> Describe Material and Procedure y§ <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District' ;. . <br /> qnd the State of Califorriia pertaining to or regu3ating well 'construction. Within FIFTEEN DAYS i <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..wel1. in.use.... The above <br /> information is true.'to the best of my:.knowledge <br />'RIOR TO GROUTING 'ANand belief. I WILL CALL FOR A 'GROUT IPECTIOk1 <br /> D TIN INSPECTION. NS <br /> SIGNED i - <br /> i ' u TITLE <br /> {DRAW PLOT PLAN REVERSE REVERSE SIDE �` ! <br />'RASE Z s R DEPARTMENT -U3$ ONLY <br /> LPP- L A IOk'.ACCEPTED BY - <br /> tDDITIONAt,`'COMMENTS i DATE . <br /> r � .l <br /> PHASE II GROUT INSPECTION .. i <br /> .; " '�^ PHASE III INAL INSPECNNSPECTIONT BY "" _ <br /> DATA INSPECTION BY } <br /> h <br /> DATE -.�. r G <br /> E H <br /> 1426y Rev. <br /> : . <br /> L 1-r <br />