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'' N JOAQUIN LOCAL HEALTH DISTRIC• <br /> FOh OFA FICEJUSE: <br /> 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 /> .pplication is $ereby iiade to the San Joa uin Local Health District for permit to construct <br /> :nd/or install the work her escribed. This ap tion is made in compliance With San Joaquit <br /> :oun r do y Ordinan <br /> Agu a No, 1862 nd t R I& nd u ~the San Joaquin Local Health District. <br /> r� 3 <br /> OB ADDRESS/LOCATION 1 CENSUS TRACT <br /> weer's Name �-�N1<-11EALDFS � Phone5�cz ���'�/ <br /> ddress City 'M,,4A/- A <br /> ontractor's Name ` .License # Phone l�S a <br /> YPE OF WORKELL <br /> eck <br /> Ch ) : NEW W <br /> ( DEEPEN RECONDITION DESTRUCTION,, p� <br /> UMP INSTALLATION / / PUMP REPAIR / J PUMP REPLACEMENT <br /> Other <br /> ISTANCE TO NEAREST: SEPTIC TANK / SEWER LINES I_� ' PIT PRIVY <br /> SEWAGE DISPOSAL,FIELD l ' CESSPOOL/SEEPAGE PIT ice, OTHER <br /> t PROPERTY LIN 42 PRIVATE DOMESTIC WELL -fla' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> " Industrial Cable Tool Dia. of Well Excavation <br /> L. Domestic/private Drilled Dia. of Well Casing ' <br /> Domestic/public Driven Gauge of Casing .,{ <br /> Irrigation Gravel Pack Depth of Grout Seal Z� <br /> Cathodic Protection i17- Rotary Type of Grout <br /> Disposal Other Other Information R <br /> Geophysical Surface Seal Installed By: _11 /i-Illoo - <br /> f JMP INSTALLATION: Contractor <br /> +I Type of Pump H.P. <br /> . <br /> , PUMP REPLACEMENT: / / State Work Done <br /> JMP ,.REPAIR: <br /> _ /� tate Work Done <br /> :S•TRUCTION -OF WELL Well :D ameter-• Approximate Depth <br /> s r7L a to ial a Procedure <br /> hereby agree to c'om 1y wit all law' and regulati ns of the an'Joaquin.Itocal Health istrlct <br /> id the State of Cali npertaining. to or regulating well'construction. Within .FIFTEEN.:DAYS <br /> Eter completion of my work on a new well, I will furnish the San -Joaquin Local Health Distrtct' a <br /> ELL DRILLERS REPORT of the well and notify them before putting. the.-well in use. The Above <br /> zformation._i,s true, to.,the.best L,ofmy. knowledge and belief. I WILL CALL F A GROUT -INSPECTION <br /> ,IOR TO GROUTING AND A FINAL INSPECTION, <br /> LGNED .dTITL . <br /> { (DRAW PLOT PL-A REVS SE STD <br /> SASE I OR DEPARTMENT USE ONLY j <br /> PPLICATION ACCEPTED B DATE j� f <br /> DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE-III/FINAL INSPECTION <br /> VSP CTION BY DATE INSPECTION BY DATE <br /> E H 1 A 2 A V— 7--7A ON Id ILV% .- 7' _ i � a� s 1L � I J 77 om ct/ <br />