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���. y SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OA,FOR OFFIU USE: q 160.1 E, Hazelton Ave. , Stockton, Calif.. <br /> Telephone: (209) 466-6781Permit No. "X10 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> " <br />'4 THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> E Application is hereby made to the San Joaquin Local Health ,District for a permit to construct <br /> and/or install theworkherein described. This application is made. "in compliance with San Joaquin <br /> County Ordinance No. 1862 and the .Rules and Re Mations of, the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �l�z CENSUS TRACT <br /> Phone <br /> Owner's Name <br /> Address <br /> city . <br /> .. ] License ��l�l3jd Phone " �r��. � <br /> "Contractor's Name <br /> TYPE OF WORK (Check) : NEW <br /> / / DEEPEN "/ / RECONDITION DESTRUCTION /-7 <br /> /�/ <br /> PUMP INSTALLATION / PUMP REPAIR PUMP REPLACEMENT / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> :y SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> " PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELD <br /> iT <br /> NENDEDiUSE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ustrial Cable Tool Dia. of Well Excavation <br /> nd �S <br /> rivate Drilled Dia. of Well Casing <br /> Dome stic/p <br /> Domestic/public Driven Gauge of Casing. <br /> k - Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 1. Rotary Type of Grout <br /> Other IAfotmation . <br /> Disposals Other_ - � - <br /> ..... ., <br /> Geophysical Surface Seal Installed BY: <br /> k <br /> PUMP INSTALLATION: Contractor" <br /> �v H.P. , <br /> Type, of Pump <br /> PUMP REPLACEMENT: <br /> State Work Done <br /> PUMP .REPAIR: / State Wark Done ' <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> k' I hereby agree to comply with all laws and regulations- of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS, <br /> t after completion of my work on a new well, I will furnisl 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 to the best of" m edge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINA S ION. <br /> SIGNED719 <br /> TITLE _ <br /> A j ( <br /> RA PLOT PLA1+ 0 REVERSE SIDE) <br /> Q FOR DEPARTMENT USE 'ONLY <br /> t -• n <br /> PHASE I .. . .._ " DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE, INSPECTION. BY <br /> 2M <br /> T N IL9A Rav_ 1-74 _. <br />