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SAN JOAQUIN LOCAL HEALTH DISTRICT j <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ! <br /> Telephone : (209) ' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l. YEAR FROM DATE ISSUED Date Issued �] <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 t <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION . zatee!6iCJ/� -- CENSUS TRACT <br /> i <br /> Owner's NameY � s — _ Phone <br /> /�} <br /> Address City E, icr,-rlon <br /> Contractor.'s Name. j"%�, Q 'r f] -- License # Phone 93f_; *, <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / % RECONDITION /_/ DESTRUCTION /? <br /> s PUMP INSTALLATION / / PUMP"REPAIR / , PUMP REPLACEMENT 7,,/7T <br /> r Other fa,...+*,' ' <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 USEr' TYPE OF WELL CONSTRUCTION SPECIFICATIONS,,' <br /> Industrial ; „ Cable Tool' Dia. of Well Excavation <br /> Dome8tic7pri.vate ", Drilled Dia. of Well Casing <br /> -Domestic/public- Driven Gauge of Casing <br /> Irrigatiari. ' - Gravel Pack Depth of Grout Seal ��'Cathodic Protection,:'Protection,' x Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical •' a Surface Seal Installed By: <br /> ,J, + i <br /> PUMP INSTALLATION: ,Contractor 1 <br /> Type of £Pump H.P. <br /> PUMP REPLACEMENT; ' - State Work Done <br /> PUMP REPAIR; f j State Work'Done <br /> s ' jr <br /> DESTRUCTION OF WELL: Well Diameter s Approximate Depth 4 <br /> f ]Describe Material and Procedure <br /> � r <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`. Tfie_above` <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A�GROUT: INSPECTI'ON <br /> PRIOR TO CWftING ANR A FI L I S ECTION. ',.o <br /> SIGNED 1' TITLE <br /> (DRAW PLOT 'PLAN ON REVERSE SIDE) r' <br /> FOR DEPARTMENT USE ONLY <br /> - I <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION `~ PHAS III FINAL INSPECTION4 <br /> INSPECTION BY DATE xz , ,�'� INSPECTION BY ,,./ DATE <br /> U 17 2M <br /> E H 11+26 Rev_ 1-74 <br />