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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO&,OFFICE USE: Z1601 E. Hazelton Ave. Stockton,c tan, Calif. <br /> Telephone: (209) 466 -6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�L) j <br /> THIS PERMIT EXPIRES I 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' <br /> County 'Ordinance No. 1862 and the Rule's and Regulations of the San -Joaquin Local Health .District. <br /> < <br /> JOB ADDRESS/LOCATION Er -ey:.J:7 <br /> CENSUS TRACT <br /> Owner's NameKe y" D Phone ' <br /> Address ! Q r - F f 611j City <br /> Contractor's Name.' License # Phone , <br /> 4 TYPE OF WORK (Check) " ,NEW WELL.'/-7 DEEPEN ,/-7 RECONDITION /_7 DESTRUCTION <br /> PUMP ,INSTALLATION J / PUMP REPAIR -/? PUMP REPLACEMENT ' /_7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY o , <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER N <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation � <br /> -�_ Domestic/private F Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation _ Gravel Pack Depth of Grout Seal �+ <br /> Cathodic Protection; AR ia7 Type of Grout <br /> Di13p9sal t Other Other Information <br /> Geophysical Surface Seal. Installed By:' <br /> l� <br /> PUMP INSTALLATION: Contractor <br /> TYPe. of Pump A H.P. . <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'REPAIR: /7 State Work Doe <br /> - . <br /> DESTRUCTION OF WELL: Well Aiameter. p ', + ,� , Approximate Dept <br /> Describe Material and Procedure ae-Y f. <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, n y them before putting- the..well. in use... The above <br /> informati is true to the•best-of. myledge and belief I WILL- CALL FOR °A GROUT INSPECTION <br /> PRIOR T GOUT FINAL INSPECT17 <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE) - <br /> -- � ....� - .- ... .. - FOR-DEPARTMENT USE ONLY <br /> PHASE I / <br /> APPLICATION ACCEPTED BY - ' ,� 'a � DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PIAS I I FINAL INSPECTION <br /> INSPECTION BY ^ DATE INSPECTION BY DATE <br />