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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> t/ 1601 E. Hazelton Ave. , Stockton, <br /> FOFK;OFF USE: Telephone: (209)' 466-6781 1,j <br /> APPLICATION FOR WELL CONSTRUC'!ION OR PUMP PERMIT Permit No. t <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued /D-�' <br /> (Complete In Triplicate) <br /> o the San Joaquin LocalHealth list de tofor a permit construct <br /> Application is hereby made tin complianceSan Joaquinl <br /> and/or install the work herein described. This application <br /> County Ordit>ance N 1862 and the Rules and Regulations of the San Joaquin Locallealth -District. <br /> ) N 42 l R.,'o CENSUS TRACT <br /> JOB ADDRESS/LOCAT1 v <br /> .. m � Phone ' <br />` Owner's Name <br /> ---------------- <br /> City , <br /> Address <br /> r License Phone <br /> Contractor's Name / T <br /> TYPE Off' WORK (Check) NEW WELL,'/ :T--;DEEPEN 'L RECONDITION �T DESTRUCTION �`T <br /> PUMP INSTALLATION / / PUMP REPAIR /� PUMP -- <br /> Other <br /> SEWER LINES _ PIT PRIVY <br /> AN <br /> DISTCE TO NEAREST: SEPTIC TANK �_ CESSPOOL/SEEPAGE PIT _� OTHER <br /> SEWAGE=DISPOSAL .FIELD � <br /> PUBLIC DOMESTIC WELL �- <br /> PROPERTY LINE -- DOMESTIC DOMESTIC WELL g <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 Gauge of-Casing <br /> • Gravel Pack Depth of Grout Seal <br /> Irrigation' - Rotary Type of Grout , <br /> Cathodic Protection y _, Other,Iuformatiou <br /> Disposal. - Other <br /> Geophysical ~ Surf ace Seal l stalled B <br /> w <br /> PUMP INSTALLATION: Contractor � R.P. _ <br /> Type of Pump <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP ,REPAIR: / / State Work Done <br /> !� t yl Approx to Depths <br /> DES'TRUCTIlN OF WELL: Well Diameter GJ.I; 6-1 r 7 <br /> f Describe Material and Procedure <br /> i <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 /> k after completion of my work on a new well, I will furnish the- San Joaquin Local Health District <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. ; _ �. -_ TITLE <br /> 5IGNED (DRAW PLOT 'FLAN ON REVERSE SIDE <br /> FOR DEPARTINT USE ONLY <br /> . PHASE I DATE /0 <br /> APPLICATION' ACCEPTED BY Uv(rt <br /> ADDITIONAL COMMENTS: PHASE II FINAL INSPECTIO <br /> 'PRASE II GROUT INSPECTION INSPECTION BY DATE S' <br /> ' INSPECTION BY DATE <br />