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/ 7�S e c�rf���,�- e•�e��1 r� s ��.• <br /> C o r� f6� C SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE;O FICE USE: , / 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued � Z6 <br /> (Complete In Triplicate) <br /> pplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> nd/or install the work herein described. This application is made in compliance with San Joaquil <br /> ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> OB ADDRESS/LOCATION J ! L Y`A Y�1.. �,2 CENSUS TRACT <br /> wner's Name r <br /> < S Phone <br /> ddress ��// �(f�t 6'?t S4— City 6iArr'," <br /> ontractor's Name tel/ License #/ �Phone &` 6 <br /> YPE OF WORK (Check).: NEW WELL/7 DEEPEN ,/ 7 RECONDITION /7 DESTR$CTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR//f/ FUMP REPLACEMENT /-7 <br /> Other <br /> ISTANCE 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 SPECIFICATIONS <br /> Industrial ! Cable Tool Dia. of Well Excavation G <br /> Domestic/private i Drilled Dia. of Well Casing <br /> Domestic/public i Driven Gauge of Casing <br /> Irrigation j Gravel Pack Depth of Grout Seal <br /> Cathodic Protection I Rotary Type of Grout I <br /> Disposal i Other . Other Information <br /> Geophysical Y Surface Seal Installed By: <br /> UMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> �- <br /> UMP REPLACEMENT: / / State Work Done <br /> UMP REFAIR: State Work Done <br /> } aw/_ <br /> ESjRUCTION 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 /> nd the State of California pertaining to or,-regulating well construction. Within FIFTEEN DAYS <br /> fter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> FELL DRILLERS REPORT of the well and notify them before putting •the .well in-use—The above <br /> nformation is true to the best of my kwledge elief. I WILL CALL OR A GROUT INSPECTION <br /> RIOR TO GRUTING AND A FINAL INSP 0 <br /> IGNED ITLE �� <br /> (DEA LOT PLAN ON RE RSE SIDE <br /> R DEPARTMENT USE ONLY <br /> 'RASE I <br /> XPLICATION ACCEPTED BY DATE V/T <br /> JDDITIONAL COMMENTS <br /> PHASE II GROUVINSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 2 - � <br />