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' SAN JOAQUIN LOCAL=-HEALTH .DISTRICT
<br /> FOFirOFFICE USE: 1601 E. Hazelton,Ave': Stockton, Calif.
<br /> Telephone: (209) 466-6781
<br /> APPLICATION FOR-WELL CONSTRUCTION OR PUMP PERMIT Permit No.
<br /> THIS,PERMIT tXPIRESA,1 YEAR :FROM,DATE :,ISSUED,_ , . o ,Date Idsued i^__ L4 _
<br /> �(CompXete ,In .Triplicate): .,. ,,
<br /> Application is hereby made to the San Joaquinl'Local Health. District for,:a,.permitto"construct
<br /> and/or:,install the.work herein des c;ribed4..--,,This applicatiotk,is:i-,made_�in--complian+ce':'with'.Sail Joaquin
<br /> County`Ordinance No..18621and the. :Rule;s.,;and Regulat•ions:-of-;,the..San doaquin,:Local"-health ,.District.
<br /> JOB ADDRESSLOCATION. _ ,R ,f: .I '•. ` io <� ��
<br /> / - . ' ' CENSUS:TRACT.._. %4 • >.
<br /> Owner's Name /
<br /> Phone ���- p19
<br /> Addt�e'ss'7;-•-.. ..
<br /> Contractor t s .Name 'License � /,ZA72�f Phone (�}��� 7.12
<br /> �7 ,_�__ j
<br /> TYPE OF WORP(Check): NEW'WELL `/�?'vDEEPEN / - RECONDITION -/7 DESTRUCTION'/ f
<br /> .1 f ,
<br /> PUMP, INSTALLATION /,77Ptll� REPAIR /� PUMP REPLACEMENT /f
<br /> f"4 Other / / �' r
<br /> DISTANCE TO NEAREST: SEPTIC.�TANK SEWER- LINES PIT PRIVY . _
<br /> SI�FTAGE DISPOSAL FIELD.�'' CESSPOOL/SEEPAGE PIT OTHER O
<br /> PPOPEk. LINE .- •PRIVATE DOMESTIC WELL PUBLIC DOMESTIC'WELL
<br /> INTENDED USE TYPE;.OF WELLS F y CONSTRUCTION..SPECIFICATIONS•-,; .
<br /> Industrial Cable Tool t Dia. .of Well Excavation
<br /> Domestic/private* Drilled € _Dia•.--Iof We'll- Casing'
<br /> Domestic/public. Driven jq C Gauge„of ,Casipng
<br /> Cathodic Protection Rotary Pack
<br /> Irri ation Gr Depth of Grout Seal
<br /> tary..,...�,.�. � .....,.,Type°'of Grout --...-_.,m,�._:. _ ... .._..,... . ...
<br /> Disposal Other .Other ,Information_ -
<br /> Geophysical g 'Surface. Seal Installed §j:
<br /> PUMP INSTALLATION: .- Contractor •� � � _. '-.4,..'.. '" , ....__ .A_.�.� . .. __ . . .
<br /> Type of Pump H.P.
<br /> . ..
<br /> PUMP REPLACEMENT: / / State Work Done
<br /> 4 -UAU.' .REPAIR; - - ,/' `St6te-1Wo4k`Dditi-
<br /> ,1RES�TRUCTION OF WELL: Well Diameter �� � Approgimate Depth
<br /> Describe Material and' Procedure
<br /> I 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..the.,well in-use.. The above
<br /> information is true to the-best-of. my- knowledge and, belief. I "WILL" CALL FORA GROUT •INSPECTION
<br /> PRIOR TO GROUTING AND A FINAL INSPECTION, . T. .
<br /> SIGNED TITLE
<br /> (DRAW PLOT PLAN ON REVERSE
<br /> "SIDE
<br /> . ,FOR DEPARTMENT. USE ONLY _
<br /> F
<br /> PHASE I '
<br /> APPLICATION ACCEPTED B ,�:�►, DATE
<br /> L :
<br /> ADDITIONAL COMMENTS:
<br /> PHASE II GROUT INSPECTION PHA I FINAL INSPECTION
<br /> INSPECTION BY DATE INSPECTION 'B ,6%ir., DATE r7 9 y t .
<br /> xE H 1426 Rev. 1-74 "f C 1-74 2M
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