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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOArOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Califo <br /> Telephone: (209) 466-6781 ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZE-LL5r <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE. ,ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is her made to the San Joaquin Local Health District for a pei.•mit to construct <br /> and/or install the workfherein described. This application is made in compliance with San Joaquin , <br /> County Ordinance No. 112 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT 11 <br /> f' Gj 0 <br /> Owner's Name �I � Phone J 6 <br /> Address.-' �w ✓ /�, CityT �� <br /> I� - <br /> Contractor's Name _ License # Phone VU La_ <br /> TYPE OF WORK (Check): ..NEW WELL '/� DEEPEN �j / RECONDITION /_ DESTRUCTION <br /> 'PUMP INSTALLATION PUMP REPAIR .jam` PUMP REPLACEMENT /? <br /> ether J j <br /> ,1i. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER°° LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD _` CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC 'DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i Cable Tool Dia. of Well Excavation <br /> Domestic/private .'. Drilled Dia. of Well Casing <br /> Domestic/public 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 /> E _Geophysical Surface Seal Installed By: <br /> ' .,Cont:ractor , <br /> PUMP .INSTALLATION: .. <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: % / State Work Done <br /> PUMP '.-REPAIR: - - - flState: Work aDone - - <br /> i� ` <br /> 42ES;TRUCTION,OF WELL: Fell 'Diameter 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 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 notify them before putting-the- well in-use.. The above <br /> I information is true to-i�the-best-of. my-knowle.dge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTING-AND`AiFINAL-'INSPECTION. <br /> SIGNED _ y' Q . ,:F. 1 TITLE <br /> iDRAW ORD PLAN ON REVERSE SIDE <br /> " 5 ` J USE ONLY <br /> . <br /> PHASE I 1 •�- <br /> APPLICATION ACCEPTED :B` DATE DATE -X <br /> ADDITIONAL COMMENTS:; <br /> PHASE II'GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY 'IM. DATE INSPECTION BY DATE <br /> 3 E H 1426 Rev. 1-74 1-74 2M` <br />