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SAN JOAQUIN LOCAL. HEALTH DISTRICT f <br /> uJ4 1601 E. Hazelton Ave. , ;Stockton, Calif. <br /> �E OFFICE vsE: ' 209 466-6781 <br /> Telephone: ( ) <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT ' , Permit No: y <br /> _ THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued <br /> ( f�T(� , (Complete In Triplicate) <br /> f l/ c/ <br /> Application 'reby made to .the San Joaqu� isLocal <br /> lication ismade inrco plianceermit twith San Joaquin <br /> and/or install the.. k herein described. ulations of the San Joaquin Local Health Dist#ct. <br /> County Ordinance No. 18 ®les an _ . <br /> CENSUS TRACT r <br /> JOB ADDRESS/LOCATION �; I <br /> Phone <br /> Owner's Name <br /> City <br /> Address"Address <br /> r icense # Phone <br /> Contractor's Name <br /> { e <br /> I TYPE OF WORK (Check) : STRUCTION <br /> NEW WELL DEEPEN / RECONDION J PiJi�EREPLACEMENT�I <br /> PUMP INSTALLATION / I PUMP REPAIRI I <br /> Other /s / <br /> SEWER LINES PIT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC TANK'jme. CESSPOOL/SEEPAGE PIT OTHER a <br /> SEWAGE DISPOSAL FIELD �-' PUBLIG DOMESTIC-WELL -g '--�' <br /> PROPERTY�LINE .-- PRIVATE.-DOME STI-C WELL--- - <br /> Ii3TENDED�i1SE TYPE OF WELL -CONSTRUGT.ION SPECIFTCATTONS ,,, <br /> Industrial 'Cable Tool Dia'. Well Excavation . <br /> ' """""""" Dia.`of We11�-Casng t �� <br /> �/- Domestic/p Drilledt <br /> - Domestic/private ,. t� ► to <br /> ublic 'Driven Gauge of Casing % <br /> Domestic/public ; <br /> Irrigation { Gravel Pack Depth o£ Grout. Seal � � <br /> Type <br /> of Grout''=,i; <br /> Cathodic Protection Rotary Other Information �^- <br /> Disposal Other — <br /> Surface Seal Installed B <br /> Geophysical <br /> PUMP INSTALLATION: Contractor <br /> Type of -PUMP <br /> •/ / Stat <br /> PUMP REPLACEMENT: . State 'Work Done�- <br /> PUMP .REPAIR: / / ± State ,Work Done <br /> E _ k Approximate Depth <br /> jDES•TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> I hereby agree to comply with allylaws and regulations of the San Joaquin Local Health District <br /> and the State. of California pertaining 0I will furnishethecSantJoaquin.LocalWithHealth Distin FIFTEEN rict <br /> after completion of my work on a new <br /> well, I 1r <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 /> - <br /> information <br /> TO OUT71 <br /> ING AND A FINAL NSPECTIO TITLE <br /> f SIGNED RAW PLOT PLAN N VERSE SID ) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � DATE <br /> �1 <br /> i APPLICATION ACCEPTED BY� <br /> ADDITIONAL COMMENTS: ' p S II/F NAL INSPECTION <br /> PRASE II GROUT INSPECTION <br /> CTIO <br /> DATE llINSPECTION D <br /> INSPECTION `BY <br /> 2-1 <br /> 1_164 0 177 <br /> / � <br />