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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR•!OFFI;CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.zl-Vc)y� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 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 Regula ons of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION. 2 t a C_kc�61 M <br /> CENSUS TRACT eA <br /> Owner's dame _4,�L2�C Phone <br /> Address 04 City�� dA . <br /> Contractor's Name 10 <br />` License <br /> __3 Phone y7_,p <br /> TYPE OF WORK Ct►eck)`:,'''NEW WELL '/� DEEPEN 17 RECONDITION /7 DESTRUCTION /7 <br /> -PUMP INSTALLATION / UMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: i�SEPTIC TANK EWER LIES T PRIVY <br /> SEWAGE DISPOSAL FIELD <�` SSPOOL/SEEPAGE Pf OTHER ----�� <br /> ' PROPERTY LINE - PRIVATE DOMESTIC WELL '' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICAT-TONSInAu <br /> strial A Cable Tool Dia. of Well Excavation ,/ / <br /> Domestic/private Drilled Dia. of Well Casing S , <br /> Domestic/public Driven Gauge of Casing 3 �} <br /> Irrigation Gravel Pack Depth of Grout Sea 4 l <br /> Cathodic Protection otary Type of Grout' <br /> Disposal ' Other Other Information•. .t �. <br /> Geophysical � <br /> �.,, --A- <br /> ce Seal Installed B . ,. <br /> x1 d - <br /> PUMP INSTALLATION: Contractor <br /> Type of Pu , . , .P. <br /> PUMP REPLACEMENT: L/ State Work Done <br /> PUMP '.REPAIR: /? State-WorkFDdne° r <br /> t <br /> ,RES�TRUCTION OF WELL: Well Diameter f <br /> . ,�. "< --Approximate Depth <br /> Describe--Materia]: and'Pfocedure `. <br /> I hereby agree to comply with all laws and regulations of the San JoaquinLocalHealth 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 /> inform tion is true to the-best of knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO ROUTING AND A F I <br /> SIGNED, N. TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> 3 FOR DEPARTMENT USE ONLY <br /> PHASE <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHA1UII G OUT INPECTION PHASX I I FINAL INSPECTIO <br /> INSPECTION BY DATE dINSPECTION BY DATE <br /> E H 1426 Revs 1- 2 <br /> 74 M <br />