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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FUR•.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 Issued /, 7� <br /> ` (Complete In Triplicate) <br /> - <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 Rule and Regulations of the San Joaquin Local Health Dist#ct. <br /> JOB ADDRESS/LOCATIO l=� <br /> LAe_ CENSUS TRACT <br /> 01 <br /> Owner's' Name Phone <br /> Address 14 City <br /> 44(,11-el <br /> Contractor's NameLicense #4a/.1;5:L Phone��n3s1- <br /> TYPE OF WORK (Check) : NEW WELL P <br /> DEEPEN/ / RECONDITION / /_7/ DESTRUCTION / - <br /> PUMP INS ALLATION / / PUMP REPAIR / / UMP REPLACEMENT /7 9. <br /> Other / / C(' <br /> P <br /> DISTANCE TO NEAREST: SEPTIC TANK /ar? SEWER LINES f 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 Cable Tool Dia. of Well Excavation /A � <br /> i_-15bme s tic/private L -.Drilled Dia. of Well Casing . <br /> Domestic/public Driven Gauge of Casing 7TE Z; a <br /> Irrigation Gravel Pack Depth of Grout Seal 457 <br /> Cathodic Protection Z--Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP -.REPAIR: / / State Work Done <br /> PESTRUCTION 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' DistrTct <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 /> PRIOR TO U NG AND NAL I PECTION. <br /> SIGNED �'�-� /'` TITLE -tN-y,./� <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASA II GROUT INSP ION PHAS III FINAL INSPECTION <br /> INSPECTION BY _ DATEINSPECTION BY DATE 7-77-- <br /> E <br /> E H 1426 /57Z f 117.7 2M <br />