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SAN JOAQUIN LOCAL HEALTH DISTRICT R <br /> "�FOF� 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 1 YEAR FROM DATE ISSUED Date_ Issued, r _;>, ' <br /> (Complete In Triplicate) <br /> Application is Aereby 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 Regulations of the San Joaquin Local Health District. <br /> 14e rj"S S GA'tv 1%/ t.. <br /> ,TOS ADDRESS/LOCATION a CENSUS TRACT <br /> • - Phone Gd3-UFf 1 <br /> Owner's Name - <br /> Address kl- o City �oknl _ <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check) : ' NEW WELL / DEEPEN / / RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION _0 PUMP REPAIR/ / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO.NEAREST: ,SEPTIC TANK SEWER LINES (� PIT PRIVY <br /> SEWAGE DISPO�ELD CESSPOOL/SEEPAGE PIT OTHER , <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USETYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> { <br /> _ Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public,t., Driven Gauge of Casing <br /> 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: dM4. .- - <br /> PUMP INSTALLATION: Contractor A <br /> -_--� <br /> Type of Pump H.P. { ---�--'. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMPREPAIR: State Work Done <br /> Approximate ^ <br /> DESTRUCTION OF WELL: Well Diameter . � A PP ate Depth <br /> P <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin LocaitealtE District , <br /> and the State of California. pertaining to or regulating well 'construction.- -.With n ,FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local .Heaith District a <br />` WELL DRILLERS REPORT of the well and notify them before putting the well in use .;.*;-.'The above , <br /> infoVm,ation is true to the € my knowledge and belief. I WILL CALL FOR -`-`.GROUT INSPECTION <br /> PRIOR ROUTING AND, A S CION. <br /> SIGNED t TITLE !' <br /> t (DRAW PLOT PLAN ON REVERSE STD � • <br /> FOR -DEPARTMENT USE ONLY <br /> PHASE " ? ' <br /> - _ .�, �_�_ -- .,DATE <br /> APPLICATION.._ACCEPTED BY . <br /> ADDITIONAL.COMMENTS: " <br /> PHASE II. GROUT INSPECTION ;` { =PHASE- 11 <br /> /FIN INSPECTIO <br /> INSPECTION AY .DATE INSPECTION BY DATE <br /> . .' n <br /> E H 1426 Rev. 174 ��F.0 Gita Fv r l t�5� �/a�J� PXeog•404Y Gd CA 770:w ".1 <br />