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' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: Y"1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466--6781 nn <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �J <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 San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regu ations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION � CENSUS TRACT c� } <br /> 1 Phone <br /> Owner's Name <br /> / <br /> Address � � (/0_"3 City .,972 <br /> qqrui i <br /> Contractor's Name ]License #d�(o d hone <br /> i� <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD r---CESSPOOL/SEEPAGE PIT OTHER <br />` PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL ;. CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool,,, ;: Dia. of Well Excavation <br /> Domestic/private Drilled �. - .Dia. of Well Casing <br /> Domestic/public Driven 46auge of Casing <br /> Irrigation Gravel Pack C. De th of Grout Seal <br /> Cathodic Protection Rotary + ,,Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal. Installed By: <br /> -PUMP <br /> : <br /> PUMP INSTALLATION: Contractor <br /> _ .Type of Pump <br /> PUMP REPLACEMENT:.�- State Work Done <br /> PUMP -.REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: well Diameter Approximate Depth <br /> 4l 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 FOR A GROUT INSPECTION <br /> PRIOR TO WUTING AN AL INSP CT1,9N <br /> TITLE <br /> SIGNED ss <br /> DRAW LOT PLAN ON REVERSE SIDE) <br /> ', FOR DEPARTMENT USE ONLY <br /> ! PHASE I j DATE b / <br /> rAPPLICATION ACCEPTED BY <br /> ' ADDITIONAL COMMENTS <br /> PHASE II GROUT INSPECTION PHAS /FIN"INSPECTTIQNINSP <br /> ECTION BY DATE INSPECTION BY <br /> • <br /> 1/77 2M <br /> N ILIA I_7A <br />