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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E0T^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-.,Issued1�7 <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 Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �� 11 CENSUS TRACT <br /> 'Tu Phone <br /> T'r <br /> Owner's Name j <br /> r <br /> , 1V el"I <br /> Address 5- City� �N <br /> Contractor's Name <br /> L _�L [� rs � License 46 ud Phone lag <br /> TYPE OF WORK (Check) :,Y NEW WELL= _ DEEPEN` ,/�/r-_.RECONDITION_./__/—DESTRUCTIQN-/­--7-.. <br /> PUMP INST LATION /` % PUMP REPAIR / / PUMP REPLACEMENT 1_7 <br /> -• Other <br /> iDIST NNCE1TO NEAREST: SEPTIC TANK SEWER LINES r PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> IN ENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Ci• <br /> ndustrial Cable Tool', } Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing U <br /> Domestic/public- ` D,,rriiven Gauge of Casing <br /> Irrigation ''" gvel Pack ,�;. Depth of Grout Seal S `� <br /> Cathodic Protection � Rostary Type of Grout <br /> ` Other Other Information <br /> Disposal <br /> Geophysical Surface Seal Installed B <br /> iPUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> [PUMP REPLACEMENT: /—/ State Work Done <br /> rPUMP .REPAIR: / / State Work Done <br /> `DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> i 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� o <br /> cnstruction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will .furni.sh the San'Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before puttingrthe. well in use.. The above <br /> 'information is..true to the best of my knowledge and belief.. I WILL CALL FOR A GROUT INSPECTION <br /> 'PRIOR T GROUTIN AND F INSPECTION. <br /> SIGNED - _,�. . _ - -- TITLE <br /> r -(DRAW-PLOT PLAN ON REVERSE SIDE) � <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> `ADDITIONAL COMMENTS: <br /> . PHA II P TION PHASE III/FINAL INSPECTION <br /> INSPECTION BY TE / 7-?7 INSPECTION BY - DATE <br /> 1777 2M <br /> F H 1L9f; Rau- 1-7-4 <br />