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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0 OFFICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. � <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES Z YEAR FROM DATE ISSUED Date Issued -/3- 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' _?&/ -C ea rH iz ;N w 7/,,._ CENSUS TRACT ; <br /> Owner's Nameg ' -,2-f�T J <br /> � ) � Phone <br /> Address C Cit <br /> i <br /> Contractor's Name '� b� iy License #,2r�I' DD Phone <br /> i <br /> _�. .^s-�.._—,.',r�TMr.'. .:.�.__..7. _-....-•-.._-;.i",_��, _'�`.:ems yd:: �r- .. .... _--_�.r 1 ,_.._ .. .. - - ' <br /> TYPE OF WORK (Check) ., NEW WELL/ / DEEPEN / / RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD `rCF'SSPOOL/SEEPAGE PIT OTHER <br /> -PROPERTY LINE - PRIVATE DOMESTIC WELL - PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> IndustrialCable ToolnDia, 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 /> Geophysical Surface_Seal_Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: --State -Wo•r1e. Done.., yti v -a ,� _ L <br /> S <br /> a <br /> PUMP�REPAIR-:---- _ /:/ State-Work Done <br /> DESTRUCTION OF WELL: Well 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 ofRmy-wo.rk„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 /> PRIOR TO GROU G AND .A FJOAL ANSPECTION. <br /> SIGNED ' TITLE <br /> (DRAW PLOT PLAN ON REVERSE SI E) <br /> r FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE ! �� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE <br /> n/77 2M <br /> H 1.426 Rev. • 1--74 <br /> i <br />