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SAN JOAQUIN LOCAL. H DISTRICT �! ` <br /> FOP, _USE 1601 E. Hazelton Ave. , ;Stockton, Calif. <br /> •� <br /> Telephone: (209) 466-6781 it <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7� <br /> s. j' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued i <br /> (Complete In Triplicate) II <br /> Application ishereby made to the San Joaquin Local Health District for a permit to construct. <br /> and/or install the work herein described. This application is.made in compliance. with San Joaquin <br /> County rOrdinance,4No X186.2 and,,.the Rules and Regulations of the San Joaquin Local Health Dist4ct. <br /> - ., ��� <br /> JOB ADARESS/I,OCATION, y�O /1/ 0,c�a <r..�u a� //0 -- 1ra�rr�_ �:3?� 'T CENSUS TRACT <br /> JI. <br /> Owner's Name Phone <br /> Address J y 2 1 Qn v ----- - - --- City <br /> Contractor's Name License # Phone C3 J s- b <br /> r.aq <br /> u - <br /> t <br /> TYPE OF WORK (Check) : NEW WELL /X DEEPEN / / RECONDITION /_7 DESTRUCTION '/_7 It <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT 17 �. <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER ,LINES PIT PRIVY . . <br /> SEWAGE DISPOSAL FIELD ' CESSPOOL/SEEPAGE PIT OTHER I� <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL C+ <br /> INTENDED USE TYPE -,OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private - Drilled. Dia. of Well Casing ,4 <br /> Domestic/public Driven Gauge of Casing 0 ,a -,IMid <br /> r Irrigation Gravel Pack Depth of Grout Seal - <br />` � Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: Al <br /> 47pVOIIP INSTALLATION: Contractor Wo ry <br /> -f <br /> a Type of Pump <br /> MP REPLACEMENT: / / State. Work Done i I� <br /> PUMP .REPAIR:: - _ / / State Work Done 2 <br /> DES`TRUCT_ION-OF WELL: Well Diameter Approximate Depth <br /> ~ Describe Material and Procedure .�� . <br /> I Hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> 4 and the State of California pertaining to or regulating well'-construction. Within FIFTEEN DAYS <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 .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 GRPUTNG AND A ZINAL INSPECTION. I� <br /> SIGNED-_- TITLEy�A- <br /> f (D W POT -P-LAN ON REVERSE SIDE) if <br />` OR DEPARTMENT USE ONLY <br /> PHASE I 'k <br />, APPLICATION ACCEPTED B _ rJ- DATE`'�J� <br /> IADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAPE INAL INSPEC I Nil <br /> INSPECTION BY DATE / INSPECTION BY ATE <br /> 1177 2M <br />