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® SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE U 1601 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 / z--,--7 <br /> I (Complete In Triplicate) <br /> 1: 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 with San Joaquin <br /> County Ordinance No. 1862' and the Rules and Regulations of the San Joaquin Local Health District. <br /> 3 <br /> JOB ADDRESS/LOCATION CENSUS- TRACT ' <br /> Owner's Name Phone ,* Z17 <br /> Address City �6SL' ql o A -- <br /> Contractor's Name t � f . 49. �.�/ nJ License �� _?220)0 'hone &� 0� <br /> 9--_ �-_ 'yF ,�:�' ���.Y...�.�,�.r_1i"•:l`—�__�_A'��a�.zs -_.F.'-.� :....w+a...�..+r.�:_.n _ -J__—..., _ - y ... ,��+.r�i 9�_.:'k_�..'�r..ir:. <br /> TYPE OF WORK (Check) : NEW' WELL / / DEEPEN / / RECONDITION /_/ DESTRUCTION <br /> € PUMP INSTALLATION /—/ PUMP REPAIR/ / PUMP REPLACEMENT <br /> other <br /> DISTANCE TO NEAREST,: SEPTIC TANK SEWER LINES PIT PRIVY <br /> j SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHER <br /> f PROPERTY LINE - PRIVATE DOMESTIC WELL '- PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL iCONSTRUCTION SPECIFICATIONS <br /> Industrial _ Cable Tool � Dia. of. Well Excavation <br /> r <br /> �Somestic/private Drilled " D3a: of Well Casing -____-- <br /> ! Domestic_public Driven Gauge of Gasing <br /> Irrigation4 Gravel Pack Depth of Grout Seal <br /> Cathod c'P'rotecti(5n . ` Rotary Type of Grdut <br /> I Disposal � `� Su�; ? Other Other Information <br /> r Geophysi.ca--I° :�rSurf aceli Seal Installed By: <br /> PUMP INSTALLATION: Contractor _ <br /> Type of Pump H.P. ' - <br /> PUMP REPLACEMENT: / State Work Done <br /> PUMP ,REPAIR: � ''/ •_/t State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure I <br /> I hereby agree to comply with all laws and regulations of 1.the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating we'll 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 pujtting thewell in use... The above <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 IZNAL,INSPECTION. t <br /> SIGNED TITLEf'/d, <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR PEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ' DATE <br /> 4z <br /> ADDITIONAL COMMENTS: <br /> k PHASE II GROUT INSPECTION PHASE I/FI INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE Z-Z 7 <br />