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f^ -. : SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> h: Stockton, Calif . ` <br /> FOk°OFE.,CE USE• 1601 E. Hazelton Ave. , � s� <br /> Telephone : (209,) ,466-6781 Permit No. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT ! <br /> �.�. <br /> Date Issued <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED w <br /> (Complete In Triplicate) permit to construct <br /> A ' lication is hereby made t.[the. San Joaquin Loa1istmade inrict rco compliance with San Joaquin <br /> PP <br /> and/or install the work herein described. The applicationG <br /> Count Ordinance.-No- 1862 and the Rules and Regulations of the San Joaquin Local. Health- D st � <br /> Y <br /> Y �-w:,� CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> eCl Phone <br /> Owner's Name �� 11 <br /> City � <br /> Address <br /> License # zgvL,P ane c 1 <br /> Contractor' s Name <br /> I! , <br /> i <br /> RECONDITION ON / DESTRUCTION <br /> DEEPEN /— <br /> TYPE OF WORK (Check) : NEW WELL / / PUMP REPLACEMENT / <br /> PUMP !INSTA LATION —/ / PUMP REPAIR <br /> Other / <br /> SEWER LINES PIT PRIVY <br /> DISTANCE TO NEAREST: <br /> SEPTIC <br /> PIT <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> SEWAGE1DISPOSAL FIELD PUBLIC DOMESTIC WELL <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL CONSTRUCTION SPECIFICATIONS U <br /> INTENDED USE I.TYPE OF WELL <br /> Tool Dia. of Well Excavation <br /> IndustrialDia. of Well Casing G <br /> x Domestic/private Drilled <br /> °�� � _ , Gauge of Casing <br /> Domestic/public- Driven Depth of Grout Seal <br /> Irrigation Gravel Pack P <br /> Rotary Type of Grout <br /> Cathodic Protection ' Other Information <br /> Disposal , Other � _ <br /> f Surface Seal Installed By': -�------- <br /> Geophysical \ <br /> PUMP INSTALLATION: Contractor _ � * H.P. ' <br /> Type of Pump <br /> PUMP REPLACEMENT: State Work Done <br /> State Work Done <br /> PUMP .REPAIR: /w-. � I <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Weil Diameter <br /> Describe Material and Procedure <br /> and re ulations of the San Joaquin Local Health District <br /> I hereby agree to comply with all laws a E Within <br /> and the State 0f AYS <br /> California pertaining to or reg1lfurngsehecSanJoaquin•Local Health TDistEEN rict <br /> after completion of my work on a new well., I w�l <br /> above <br /> WELL DRILLERS REPORT of the well and notify t ma eforeilpettig���� CALL FOR AeGROUTeINSPECTION <br /> information is true to the best 0 knowledge <br /> PRIOR TO G TNG. AN A FINAL INS C 0 TITLE <br /> SIGNED ( W PL T PLAN ON R RSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> ' APPLICATION ACCEPTED 7BY <br /> ADDITIONAL COMMENTS: P S I /FINAL INSPECTION <br /> PHASE II GROUT OUT INSPECTION BY DATE \-off- <br /> INSPECTION BY- DATE J <br /> L � 077 <br />