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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF.OFFICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. ' LJ�S <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 <br /> (Complete In Triplicate) <br /> Application is hereby made to the Sari 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 an4 the les and gulat'or� of t e San Joaquin Local Health District. <br /> g�s^ G f y— <br /> JOB ADDRESS/LlCATIlN ��t ��� �U CENSUS TRACT <br /> Owner's Name —� <br /> a� Phone <br /> on <br /> Address as' '7- S , city 1TR�s <br /> Contractor'sName !64`S el, License # Fhone5L=3S�f <br /> TYPE OF WORK;(Check) : NEW WELL/ / DEEPEN / / RECONDITION /—/ DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> -Other-/7-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 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 v Gauge of Casing <br /> X 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 IN$TALpLATION:/ Contractor _-1aF j►�pre -Op ave CP , Y ! <br /> Type of Pump _ ��rh� H.P. ( s <br /> PUMP REPLACEMENT:� / / State Work Done <br /> i <br /> PUMP .REPAIR: / / State Work Done � <br /> i <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth - <br /> Describe Material acid Procedure <br /> Y <br /> t - _ - - <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 we11 ,`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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED 15&IM TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ., <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I INAL SPECTIO <br /> INSPECTION BY DATE INSPECTION BY E <br /> -E H 1426 ... - �` ..".� 2M <br /> Rev. 1-74 .. . -. ---•-r <br />