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SAN JOAQUIN LOCAL..HEALTH DISTRICT rte` <br /> FOE OFFICE USE: ' 1601' E. Hazelton Ave. , Stockton, Calif. V' <br /> Telephone: ' (209) 466--6781 Permit No, <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED -- 4 <br /> (Complete In Triplicate) <br /> i <br /> a permit <br /> Application is $ereby made to the San Joaquin Loaallcationalth Distmade inrict rcompliance twith nSan Joaqu3n4 <br /> and/or install the work herein. described. This PP i <br /> County Ordinance No. 1862 and 'the Rules and Regulations of the+ San Joaquin Local Health District. <br /> I CENSUS TRACT <br /> JOB ADDRESS/LOCATION'- <br /> Phone 7 6 <br /> Owner's Name # <br /> . City <br /> Address ` 3 � <br /> License 4� 3 Phone <br /> Contractor's NamAZ <br /> e <br /> `, � a; <br /> RECONDITION /_7 DESTRUCTION �a00W 1 <br /> TYPE OF WORK (Check) ; NEW WELL / DEEPEN / Pip REPLACEMENT I�T <br /> PUMP INSTALLATION fI PUMP REPAIR / <br /> Other / <br /> LINES PIT PRIVY <br /> DISTANCE TO NEAREST:rNSEPTIC TANK SEWER OTHER <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT r <br /> PUBLIC DOMESTIC WELL r ` <br /> I PROPERTY LINE - PRIVATE DOMESTIC WELL CONSTRUCTION SPECIFICATIONS , . W <br /> INTENDED USE TYPE OF WELL C <br /> Industrial Cable Tool ` Dia...of Well Sasing <br /> ation <br /> l Domestic/private <br /> Drilled Dia. of Well + <br /> Gauge of Casing <br /> Driven <br /> Domestic/public Depth of Grout Seal x <br /> Irrigation Gravel Pack P <br /> Type of Grouts <br /> Cathodic Protection Rotary Other Information <br /> Disposal Other <br /> Surface Seal Installed By: a <br /> Geophysical <br /> ION; ontractor <br /> PUMP INSTALLAT H.P. = <br /> . Type of Pump <br /> F <br /> PUMP REPLACEMENT: / / State Work Done. <br /> � PUMP '.REPAIR: I / State Work Done <br /> 1 Approximate Depth <br /> I flESTRi3CTI0N OF WELL: WelliDiameter <br /> Describe Material and Procedureation of -�- <br /> -San Joaquin <br /> cal <br /> lt <br /> I hereby agree to comply with all laws and regelulating we11�'construction.LOWithinaFIFTEENtDAYS <br /> and the.State of California pertaining to or gDisti <br /> alt <br /> after completion of my work on a new well, I hemlbeforesputtingh the aJoaquin Local He <br /> the well inuse. Thehabover ct a <br /> WELL DRILLERS REPORT of the well and notify t <br /> information is true to the best of my. knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FI AL IN PECTION. TITLE <br /> SIGNED (DgUW PLOT PLAN ON REVERSE SIDE) <br /> 1 Q <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE r � <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE /FIN INSPECTION - <br /> PH)AkS. I G INSPECTION INSPECTION BY DATE' <br /> INSPECTION BY DATE /� <br />