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1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 'OR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. i <br /> Telephone : (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> F <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuedc� <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. 186and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB AD 71 <br /> LOCATION 0 NSUS TRACT r <br /> Owner's Name Phone <br /> F „ <br /> Address ,� �' City r /` <br /> Contractor's Name License # Phone <br /> 1 TYPE OF WORK_ (Check) NEW ELL ' _ EEPEN / /�REGONDITION{_I}�IDESTRLiCTION <br /> x PUMP LATION / / PUMP REPAIR % / PUMP REPLACEMENT <br /> Other <br /> W <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 1 <br /> SEWAGE DISP A-FIELD 1 CE SPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL ; <br /> INTENDED-USE.." TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial able Tool . Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/Public Driven Gauge of Casing <br /> I ___ irrigation Gravel Pack DeptW of Grout Seal <br /> CathodicProtection Rotary Type of Grout <br /> Dispos•a-l- Other Other! Information <br />€ Geophysical Surface Seal Installed By: <br /> I <br />, PUMP;;LNSTALLATION: ':Contractor <br /> Type of Pump i H.P. <br />" PUMP REPLACEMENT: / / State Work Done } <br /> — � a <br /> PUMP .REPAIR: _ /—/. State Work'Done T / , <br /> A/ 4-1 <br />: DESTRUCTION OF WELL Well Diameter Approximate Depth -3w/I <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 st of. my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />'PRIOR TO -GRA13TINC ANP A FYW ASPVCTION. r <br /> SIGNED i J. TITLE <br /> Az/)v RAW PLOT PLAN .mON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> APPLICATION ACCEPTED BY DATE <br /> -A� <br /> ADDITIONAL COMMENTS: i <br /> + PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> GINSPECTION BY DATE INSPECTION BY DATE 1: <br /> k `7 hM <br /> E H 1426 Rev_ 1-74 1 . <br />