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SAN TOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E,,.,lazelton Ave. , Stockton, Calif„ <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ) 9.�/3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuf-H <br /> (Complete In Triplicate) <br /> ication is hereby made to the San Joaquin Local health District for a permit to construct <br /> Tor install the work herein described. This application is made in compliance with San Joaquin <br /> my Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> -ADDRESS/LOCATION T 7d /,�� _ CENSUS TRACT <br /> i s Name 1'L ' ��� � —_-- Phone e'' <br /> r e s s � l�/�`�-! c� -------— City <br /> tractor's Namedam (JJ� ------ License IL hone <br /> Fg <br /> -- Z� <br /> OF WORK (Check) : NEW WELL & DEEPEN /_/ m_-CONDITION /_; DESTRUC:TION <br /> PUMP INSTALLATION / „/ PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> _ANCE TO NEAREST: SEPTIC TANK �,( SEWER LINES PIT PP.IVY - <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER _ <br /> PROPERTY LINE - PRIVATE_DOMES'I'IC W}?LL. --- PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL. — CONSTRUCTION SPECIFICATIONS <br /> _ Industrial _ Cable Tool Dia. of Well Excavation � <br /> - Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing %n <br /> Irrigation - Gravel Pack Depth of Grout Seal <br /> _ Cathodic Protection �`- Rotary Type of 'Grout- <br /> -Disposal <br /> GroutDisposal Other Other Information <br /> -Geophysical. Surface Seal. installed By: 1 � � <br /> INSTALLATION: Contractor ice” <br /> .. <br /> Type of Pump J- �C�' --- 11.P. <br /> REPLACEMENT: / / State Work Done <br /> P REPAIR: / / State Work Done <br /> RUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> reby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> er completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> b rmation is true to the b st o my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> JR TO TING AND A FI AL E TION. -- V - <br /> IED TITLE ' <br /> _ DRAW PLOT PLAN ON REVERSE <br /> / FOR DEPARTMENT USE ONLY <br /> E" I <br />•_,ICATION ACCEPTED BY �� DATE -� <br /> -- r -- _�� <br /> )ITIONAL COMMENTS: --- <br /> PI OUT INSPECTION PIAASE III/FINAI, INSPECTTON <br /> VECTION BY AT1. �c-•_ )f.;- INSPisCTION BY E /y,T— DAT1: <br />