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' I SAI�AQUIN LOC,PL. F",%,p�LTH DISTRICT <br /> _- Vie.- Y <br /> FFOF ' OFFICE USE: 1601 E;--Hazelton Ave. , ,Stockton, Calif <br /> _ Telephone: (20R) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _S <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 5- '2 <br /> (Complete In Triplicate) <br /> kpplication,is $ereb 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 Ordinaxice 'No: 1862 and the Rules and Regulations of the San Joaquin Locc <br /> �r, ,/f �11D. .. � - j,�11LC. I��2� Ql CENSUS TRACT <br /> JOB ADDRESS/LOCATION f�..�,P, �.,:r:. _.�� <br />(Owner's Name Phone <br /> City <br /> Address . <br /> License # Phone 9 41 <br />:Contractor's Name <br />''TYPE OF WORK (Check) : NEW WELL jo DEEPEN /7/ RECONDITION /� DESTRUCTION /? <br /> PUMP INSTALLATION'/- / PUMP REPAIR '/ / PUMP REPLACEMENT I7 <br /> Other <br /> r <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE- PIT OTHER <br /> PROPERTY LINE - PRIVATE DOME <br /> TN <br /> PUBLIC DOMESTIC WELL <br /> INCONSTRUCTION SPECIFICATIONS <br /> TYPE OF WELL <br /> TENDED USE ; <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Drilled Dia. of Well Casing z r <br /> Domestic/private Driven - Gauge of Casing A <br /> Domestic/public <br /> Irr.igatian Gravel Pack - depth of Grout Seal <br /> Rotary Type of Grout <br /> Cathodic protection Other Information :j -� <br /> Disposal Other <br /> Geophysical Surface Seal Installed B :, h <br /> A <br /> PUMP INSTALLATION: Contractor ,r <br /> H.P <br /> Type of Pump.. + <br /> pUMP"REPLACEMENT: / State Work Done <br /> Pi11� .REPAIR: State }Work Done <br /> Approximate Depth <br /> DP,S•TRUCTION OF WELL: .. Well Diameter <br /> Describe M,aterial' and Procedure <br /> rict <br /> cal <br /> I- hereby agree to comply with all laws and `regulations ofthe <br /> �'construction.San Joaquin LeWithinaFIFTEEN.,DAYS <br /> and the. State of' California' pertaining to or' regulating w <br /> after completion of my work on a new well, I willbfurnishefore puttingthe. atheowellninouse.cal HeThe h bove%." 8 <br /> .WELL DRILLERS REPORT of- the well and notify t <br /> hem information is true .to the best of' my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION , <br /> PRIOR TO GR UTING AND A FINAL,.,~I SPECTION. TITLE <br /> SIGNED (D PLOT p ON ERSE SIDE <br /> FOR DEPARTMENT USE ONLY x <br /> PtLkSE I DATE ' <br /> APPLICATION ACCEPTED BY G <br /> ADDITIONAL COMMENTS: - p gE /FIN INSPECTION �a <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE �! <br /> INSPECTION BY DATE <br />