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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO -OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <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 /> (Complete In Triplicate) <br /> ct <br /> Application is hereby made to the San Joaquin Local <br /> licaHealth <br /> ionDistrict <br /> made for <br /> In complianceermit to cons <br /> SanuJoaquin <br /> and/or install the work herein described. This app <br /> lations of the San Joaquin Local Health District. <br /> County Ordinance No. 1862 and the Rules and Regu <br /> JOB ADDRESS/LOCATION <br /> AjT 4 CENSUS TRACT <br /> Phone ` <br /> Owner's Name L <br /> City <br /> Address —7��� <br /> Contractor's Name s , 0� �0j License #; ,��Phone / <br /> TYPE OF WORK (Check) : NEW WELL I��I DEEPEN/ / jRECONDITION / / DESTRUCTION /-7 <br /> P13NP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT <br /> Other <br /> 3 <br /> I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT PRIVY <br /> SEWAGE DISPOSAL FIELD ! CESSPOOL/SEEPAGE PIT OTHER <br /> STIC WELL <br /> PROPERTY LINE ::_PRIVATE DOMESTIC WELL CONSTRUCTION SPLIC ECIFICATIONS <br /> INTENDED USE TYPE OF WELL <br /> 4 Industrial Cable Tool Dia. of Well Excavation <br /> j Drilled Dia. of Well_Casing <br /> _Domestic. private. - - Driven i Gauge of Casing <br /> Domestic/public De th of-Grout Seal <br /> � <br /> Irrigation Gravel Pack 4 P` <br /> ' �- T-. e, of Grout <br /> -'C,atl odic.:Pr_ote'ct-on <br /> RotaryOther tary Other Information <br /> �. <br /> +% 1 Disposal , � Surf ace Seal -Installed B <br /> Geophysical <br /> k <br /> f PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump - <br /> �1� <br /> PUMP REPLACEMENT: State Work Done 3 <br /> State Work"Done`'' ; <br /> --,PUMP-REPAIR: `' - " _ lI^I=, ^ <br /> DESApproximate DESTRUCTION OF WELL: Well Diameter a '� Depth C <br /> Describe Material and Procedure <br /> I hereby agree to COMP with all laws and regulations of the' Sari'ructi n Lo Ithi alth District <br /> and the State of California pertaining to or regulating wethecSanCty . -L calhH —..Distr. t <br /> after completion of my work on a new well, I will furnishJoaquin <br /> WELL DRILLERS REPORV of the well and notify them before putting the well in use.. The above <br /> informatiohis _true—to�the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTW AND A NAL-.INSPECTION. <br /> TITLE <br /> SIGNED i <br /> z (DRAW PLOT PLAN ON REVERSE SID ) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED-BY <br /> ADDITIONAL COMMENTS: P II IN. INSPECTI <br /> PHASE G I PECTION INSPECTION BY DATE <br /> INSPECTION BY DATE - <br /> 1177 - 2M <br />