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'P 4 SAN 3DAQUIN LOCALALTH DISTRICT <br /> FOF� OFFICE SE. 1601 E. Hazelton Ave, ,' Stockton, Calif. <br /> V <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <br /> In Triplicate) <br /> {Complete. p <br /> Application ia' hereby made to the San Joaquin Local Health District for-..,*. permit to construct <br /> and/or install the work herein described. This a plication 'ii made.- in compliance with San'Joaquin' <br /> and Regulations of the San Joaquin Local Health District. <br /> County Ordinance No. 1862 and the.Rules � <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATIONX GV F i <br /> 5 rr Pht�ne <br /> Owner s Name , . <br /> =y .City;: <br /> Address 97L <br /> aLiZZ <br /> License # PhcTi�E <br /> Contractor's Name <br /> TYPE OF WORK {Check): NEW WELL DEEPEN 'I=T RECONDITION rT UCTION 1=1r <br /> PUMA INSTALLATION / / PUMP REPAIR PUMP ' I:ACEMENT <br /> Other 1 <br /> DISTANCE TONEARE5T: SEPTIC TANK 10D SEWER LINES PIT PRIVY t <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT y. OTHER <br /> PROPERTY- LINE - PRIVATE DOMESTIC WELL'S PUBLIC DOMESTIC WELL \n <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS V1 <br /> Industrial Cable Tool. Dia. of Well Excavation <br /> Drilled Dia. of Well Casing <br /> Domestic/public <br /> Domestic/private _ '----'- Driven Gauge of Casing <br /> Irrigation - Gravel Pack- Depth of Grout Seal <br /> Cathodic Protection !/ Rotary Typetof Grout . <br /> Disposal Other Other I•nformatibn <br /> Geophysical ��� _� face Grout,Installed" B <br /> PUMP INSTALLATION: " Contractor_ <br /> j Type ;of Pump f'4 H. - <br /> I y. . <br /> PUMP REPLACEMENT: <br /> / / 4State Work Done <br /> PUMP .REPAIR: / State Work Done <br /> proximate Depth <br /> DES-TRUCTIDN OF WELL Well Diameter <br /> F Describe Material. and Procedure <br /> I 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 /> after completion of my work Ion a new well, I will furnish the San Joaquin Local Health District a <br /> I 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 my.knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR TING AND FI INSP IO ,. TLE <br /> SIGNED <br /> k DRAW T P ON REVS SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE / <br /> APPLICATION ACCEPTED BY <br /> kADDITIONAL COMMENTS: PHASE III FINAL INSPECTION <br /> "PHASE II GROUT INSPECTION INSPECTION BY DATE <br /> INSPECTION BY DATE Y <br /> ff I't ? 2M <br /> v°u 149A - Voti_ 1-71A <br />