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FOE*;* SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. <br /> Stockton, Calif. <br /> Telephone: (209) 466-6781 ��®� <br /> APPLICATION FOR WELL CONSTRUCTION `OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 .YEAR FROM zDATE:ISSUED , Date Issued <br /> Application is hereby ma$eCom <br /> ( plete In Triplicate) . <br /> "'to the San Joaquin Local Health District for. a ,,permit::to.construct <br /> and/or install the work herein described. This application is'made..�a.. com lfance.with iSan ,joaquin <br /> County Ordinance No: 1862 and'•�te Rulesand Regulations o£ the .San.Jvaquin Loca . Health Digtrict. <br /> y ,445 t1. <br /> JOB ADDRESS/LOCATION .: <br /> ~.� <br /> L Gt�u CENSUS TRACT <br /> Owner's Name e <br /> Phone- <br /> Address <br /> honeAddress <br /> city-- <br /> Contractor's NameAlljf­ „ _ L ; <br />' <br /> License.4 Phone <br /> 4 r R <br /> TYPE OF WORK (Check) : .,-NEW WELL /17 DEEPEN /7 RECONDITION /_7 DESTRUCTION /_7 <br /> 'PUMP. INSTALLATION / PUMP REPAIR/_7 PUMP REPLACEMENT J 7- ' <br /> Other ./ / <br /> -DISTANCE TO NEARESfi: SEPfiIC TANK <br /> . SEWER LINES . - FIT PRYVY <br /> SEWAGE DISP05AL FIELD CESSPOOL/SEEPAGE FIT . OTHER ,, _ <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 <br /> Domestic/public -- — Drilled Dia. of Well Geeing '/ <br /> Driven-.F = Gauge-of rCasing <br /> Irrigation x <br /> . - Gravel Pack Depth of Grout Seal" <br /> Cathodic Pr_otect__ion Rotary Type of Grout. <br /> Disposal Other - ; <br /> Geophysical --..-�� . ether Information <br /> Surface Seal Installed 'B : C� <br /> PUMP INSTALLATION: Contractor fya�r <br /> Type of .Pump <br /> H.P. <br /> PUMP REPLACEMENT: Ll State Work Done <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter r <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with a1I. 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 /> information is true to the-best-of- my-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />?RIOR TO GR ING AND A FINALINSPECTION. <br /> SIGNED <br /> TITLE <br /> (DRAW PLAT PLAN ON REVERSE SIDE i <br /> PHASE I FOR DEPARTMENT USE ONLY 1 <br /> APPLICATION ACCEPTED BY <br />!ADDITIONAL COMMENTS DATE <br /> PHASE II OUT INSPECTION PHASE III FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY . . ' <br /> DATE <br /> E H 1426 <br />