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_ J JOAQUIN LOCAL HEALTH DISTRIC <br /> FOFz OFFICE USE: 16011wE. Hazelton Ave. , Stockton, Car�f. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 _-23'id <br /> 77-,�f6 p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby 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 Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> la <br /> JOB ADDRESS/LOCATION A O S tJ CENSUS TRACT <br /> Owner's Name C y. !ti Phone <br /> Address �j 3 '(�' t)_6� �l O S t 12 I� f �- City <br /> Contractor's Name J /} ' 1 IU F) S PU 0', License &)03 CS3 Phone <br /> TYPE OF WORK (Check): NEW WELL /'t/ DEEPEN /—T RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR /_7 PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK J00 SEWERLINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 3�( CESSPOOL/SEEP!GE PIT , OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL,!QP PUBLIC DOMESTIC WELL �1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �\ <br /> Industrial Cable Tool Dia, of Well Excavation C S <br /> Domestic/private Drilled Dia. of Well Casing / <br /> Domestic/public Driven Gauge of Casing W <br /> 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: _ /7 M e <br /> ?UMP INSTALLATION: Contractor Vj r S 21-R 1J �kJ t C G <br /> Type of Pump A.P. <br /> ?UMP REPLACEMENT: / / state Work Done <br /> ?UMP .REPAIR: / / State Work Done <br /> iESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> _ hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ind the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> ifter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> TELL DRILLERS REP(,)RT of the well and notify them before putting the well in use. The above <br /> .nformation tr4e to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TO G1 G AND A FINAL INSPECTION. <br /> IGNED _ `. ;" 7 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> 'RASE I <br /> ,PPLICATION ACCEPTED7j DATE ' <br /> J)DITIONAL COMMENTS: a+�G . '. `= cf�s' >i , 'a", <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> .NSPECTION BY DATE INSPECTION BY DATE <br />