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SAN JOAQUIN -LOCAL. HEALTH DISTRICT <br /> FOE.OFFICE USE: ' 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 5 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3 <br /> (Complete In Triplicate) <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 application is made in compliance with Sax# Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin ocal 1jealth District. <br /> NEW Hoc9 ZSE' Q r - <br /> JOB ADDRESS/LOCATION CAP <br /> - - <br /> Owner's Name Phone <br /> Address In City <br /> Contractors Name ,... . _.— _,,.._..._... . - ' License r, <br /> Contractor's GQE"Q I � �J rnP ense # Phone-121:5!_ <br /> 'rj!_ _ <br /> f" - <br /> TYPE OF WORK (Check): NEW WELL -F7/7 DEEPEN�:t^ A � �� _ <br /> � { _ �/�° � RECONDITION _/-7,_ AE$TRLT,CTION /-7 <br /> PUMP INSTALLATION / UMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST:, SEPTIC TANK -�;_ . {; h)SEWER LINES PIT PRIVY . . <br /> 7 -- � SEWAGE DISPOSAL FIELDCESSPOOL/SEEPAGE PTT _ <br /> OTHER <br /> =1 `.PROP-ERTY LINE_--.PRIVATE =bOMESTIC WELL PUBLIC DOMESTIC WELLC <br /> INTENDED USE TYPE OF WELL.. -.' CONSTRUCTION SPECIFICATIONS <br /> IndustrialCable Tool` Dia. of Well Excavation <br /> { pomestic/private , Drilled;':'. Dia. of Well Casing <br /> I Domestic/public Dr-iven i Gauge of Casing <br /> ---,- g g <br /> Irrigation ? Gravel Pack -t2 Depth of Grout Seal <br /> -; Cathodic Protection Rotary `ay Type of Grout <br /> Disposal Other Other Information <br /> Geophysical fi .; 'Surface Seal Installed By: , <br /> PUMP INSTALLATION: Contract r,Type of Pump _._�5� ?.CY, 'S- --h�2. <br /> PUMP REPLACEMENT: . / / StAte Work Done <br /> Ir <br /> .' _ ,� _ _� ,- _. <br /> �'""PUMPREPAIR: / / StateWork Done <br /> i DESTRUCTION-"OF WELL..: ---We11--Diameteri - -- _ - -- -Approximate Depth <br /> Describe Materialcand Proce'dure ' <br /> I hereby -agree to comply with all• laws and regulations of' the San Joaquin Local Health istrict <br /> and the State of California pe'rtaining to or regulating well construction. Within FIFTEEN 'DAYS <br /> after completion of my work ona new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERSZRTof thewell and notify them before putting the wall in use. The above <br /> informatioo the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO ``A FINAL INSPECTION. . ; <br /> SIGNED i TITLE � . A . <br /> (DRAW PLOT PLAN.-, ON REVERSE SIDT <br /> i y FOR DEPARTMENT USE ONLY <br /> PHASE I $ r <br /> APPLICATION ACCEPTED BY' ,,,� DATE 19, <br /> ADDITIONAL COMMENTS: a <br /> PHASE ,TI` GROUT INSPECTION PHASE 11/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY �. ATE , ^? <br /> f' E H 142.6 Rev. 1-74 <br />