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4eq 7— .4!: 6 <br /> *7..� SAN JOAQU�N LOGAL HEALTH DISTRICT <br /> FOF OF_FrG-E-*4JSE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> r" I Telephone: ' (209) 466-6781 <br /> APPLICATION FOR WELL.CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - Date Issued zp-/6-2g' <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and ulatio f the San Joaquin Local'Health District. <br /> T <br /> [JOB ADDRESS/LOCATION "� CENSUS TRACT - 1- <br /> Owner's Name D Phone 6 qL/ <br /> Address City <br /> n �pgr 52:2-031 <br /> 'Contractor's Name .. "`License # Aone <br /> jTYPE OF WORK (Check} : NEW WELL /* DEEPEN /_/ Y RECONDITION / / DESTRUCTION /? <br /> ? <br /> PUMP INSTALLATION / / PUMP REPAIR / '/ PUMP REPLACEMENT / <br /> Other / / IC <br /> +Dc <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 'CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFIC S <br /> ustrial 3 Cable Tool Dia. of Well Excavation C-1 ff <br /> + Domestic/private I Drilled Dia. of Well Casing <br /> y. Domestic/public I Driven , Gauge of Casing <br /> Irrigation ► avel Pack Depth of Grout Seal <br /> Cathodic Protection ! Rotary Type of Grout <br /> ' Disposal i Other Other Information <br /> y Geophysical . ,' E Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /% State Work Done <br /> ,.PUMP REPAIR: / / State-WorkiDone - -- <br /> 'DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> jI hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> `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 thew 1 in u The above <br /> Kinformation is true 'to the-best of my k wledge and belief. I WILL FOR !GROUT ECTION <br /> PRIOR TO GRO G-AND A FTN NS CTIO ` <br /> SIGNED TITLE <br /> p W. PL T' ON RE ERSE SID <br /> FORD ARTMEEJT- USE ONLY <br /> s.PHASE I <br /> APPLICATION ACCEPTED BY DATE l C� <br /> ADDITIONAL COMMENTS: f <br /> PHASE• II QRQUT INSIMECTIgE PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE ! INSPECTION BY DATE <br /> 3/765M <br />