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SAN JOAQUIN LOCAL HEALTH DISTRICT 7 <br /> FOR OFFICE-USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PER <br /> Permit Na. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - Date Issued <br /> (Complete In' Tripl.icate) <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. 1862 and the Rules and Regulations of the San .Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 16178 S " 141-OR1_ cg, �� CENSUS TRACT <br /> Owner's Name Phone - <br /> Address , City <br /> Contractor's Name License # Phone Sj2jLd -- <br /> c/ <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /_/ RECONDITION / / DESTRUCTION /rT <br /> PUMP INSTALLATION / / PUMP REPAIR /.. I PUMP REPLACEMENT / <br /> Other <br /> J DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ' PIT PRIVY Gr <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER T <br /> 4 PUBLIC DOMESTIC WELL r p� <br /> )" ,PTLOPERTY,'L NE �- PRIVATE DOMESTIC WEfaI <br /> INTENDEDTUSE•- �� �� TYPE yOR WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _ -Cable Tool - Dia. of Well Excavation T <br /> �p* :-� ",• %°, , _..� D `-bi- r�of Well. Casing <br /> Domestic' rivate <br /> Domestic/pubElc't �, <br /> -7-0)riven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Type Cathodic Protection Rotary - yP of Grout <br /> _.__ « <br /> Disposal_r --Other Other Inf�rma'tion ; <br /> fi Geophysical IN <br /> Surface Seal Installed_,B <br /> PUMP INSTALLATION:INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump ' <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work Done x _ <br /> DESTRUCTION OF WELL: Well. Diameter J Approximate Depth <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 "constYuction. 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.ICALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND -A FIN4 INSPECTION. <br /> TITLE <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE —d <br /> f APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> F PHASE II ROUT INSPECTION PHAS /FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 2M <br />