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. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F7FZF CCE�USE- 1.601 E. Hazelton Ave. , Stockton, Calif. ' <br /> Telephone.: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMITermit No. � Wtcl <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,6-- Z <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 iA compliance with San Joaquin <br /> County Ordinance No.: 1862 and the Rules d.-7 <br /> _ ulations of the San JL uin Loealth, District. <br /> G�. <br /> JOB ADDRESS/LOCATION `f- � CENSUS TRACT <br /> Owner's Name CT Phone <br /> �- <br /> Address City <br /> Contractor's Name 2 License #01 AY/1-3 Phone <br /> if <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / / RECONDITION / I DESTRUCTION /_7 <br /> PUMP INSTLATION / / PUMP REPAIR / I PUMP REPLACEMENT /? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE D1SP SAL ,FIELD CE SS POOL/SIEPAGE ftT "OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WEL PUBLIC DOMESTIC WELL;F <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �y <br /> Industrial ; Cable Tool Dia. of Well Excavation <br /> trBomestic/private 1:7 — rri.lJ.ed Dia, of Well Casing <br /> Domestic/public'* Dr iv n Gauge of Casing \� k <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection �Rbtary Type of Grout <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor �e <br /> Type of Pump 4 H.P. <br /> PUMP REPLACEMENT: / / State Work Done t' <br /> PUMP .REPAIR: / / State: Work Done ' <br /> DESTRUCTION OF WELL; Well Diameter x Approximate Depth <br /> Describe Material a d Procedure <br /> I hereby agree to comply with all laws an�jV egulations of the San Joaquin Local Health District <br />, and the State of California pertaining to or regulating well 'construc Within FIFTEEN DAYS <br /> after comp,jetion of my work on a new well, I will furnish the San J quin,Local Health District a <br /> tforma <br /> LL DRILLERS REPORT of the well and notify them before putting the well 'n use. The above <br /> Aion •is true a the best of my knowledge and belief. I WIL C FOR A G UT INSPECTION <br /> PRIOR T G 0�3 ING AN INAL INSPECTION. ! , <br /> SIGNED r TITLE C1 <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> II DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br />`ADDITIONAL COMMENTS: <br /> PHA E I GROUT INSPECTION PHAS II/F AL INSPECTTO <br />` INSPECTION BY -DATE INSPECTION BY DATE <br /> 4lr <br /> /�l l am' - --. 'IV. �. 2H <br /> P ,��� moo„ ,_�� � �� y� <br />