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T F <br /> !/ t� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOPS:,OFFICE USE: 1501 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 2,7 <br /> (Complete In.Triplicate) . . . 1 <br /> 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 appXication is made in compliance with San Joaquin' <br /> County Ordinance No. 1862 and the Rules and Regulations of theSanJoaquin Local Health District. <br /> JOB ADDRESN ® ENsus TRACT <br /> w . <br /> Owner's Name Phone <br /> Address - a. City . . <br /> Contractor's Name �� r v License r _ hone <br /> TYPE OF WORK (Check): NEW WELL 'DEEP -7 RECONDITION /_ DESTRUCTION / 7 <br /> PUMP INS ALLATION /2V—PUMP REPAIR -/% PUMP REPLACEMENT /_ <br /> Other — — <br /> DISTANCE TO NEAREST: SEPTIC TANK _5_0.!f--SEWER LINES,!_��4_- PIT PRIVY <br /> SEWAGE DISPOSAL FIELD '�-- CeSSPOOL/SEEPAGE PIT efc9t-9o1-OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELIr�! PUBLIC DOMESTIC WELL " <br /> INTENDED USE TYPE OF WELL 'CONSTRUCTION SPECIFICATIONS � <br /> Industria], Cable Tool Dia. 'of Well Excavation �r <br /> 'Domestic/private Drilled Dia. of Well Casing. 4/ � <br /> IDomestic/public Driven Gauge of Casing 2-m I <br /> 'Irrigation Gravel Pack Depth of Grout Seal' <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal `Other Other Information ' " <br /> Geophysical . Surface Seal Installed By: ._ <br /> PUMP INSTALLATION: - Contractor <br /> Type of Pump 1 " H.P. 7 <br /> PUMP REPLACEMENT: / / State Work Done { <br /> • Vit. ... _ _ _ - . _ _ .w <br /> PUMP. ,REPAIR: / / , :State Work Done <br /> DESTRUCTION OF WELL: ;-;Well Diameter, Approximate Depth /per <br /> t —Describe Material and Procedure - <br /> I hereby agree to comply-with all laws and regulations rof the_San-d-oaquin Local Health District <br /> ,and the State-of California'pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after'.compleiion of my work on anew 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 INSPE CIIO <br /> SIGNED TITLE f r� <br /> D W PLOT P REVERSE SIDE <br /> FOR PM <br /> PARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT. INSPECTION PHASE III FINAL INSPECTION <br />; INSPECTION BY DATE INSPECTION BY DATE - -2Z <br /> E H_1425 A _ 1:.71. 1,/71 9M <br />