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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> _F_0F 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 /> 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 CENSUS TRACT <br /> Owner's Name Phone -- � ?2LIZ <br /> Address <br /> City, , <br /> Contractor's Name License #� Phone <br /> TYPE OF WORK (Check) : NEW WELL/�/ DEEPEN '/ / RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION / J PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <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 Cable Tool Dia. of Well Excavation <br /> omestic/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 H.P. <br /> PUMP REPLACEMENT �/&N S t~en_Work Done <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 arid-"regula-ions of the San Joaquin Local Health District <br /> land the State of- California pertaining to or regulating ;we'l'l "construction. Within,FIFTEEN DAYS <br /> after completion of my work on a new well, I will 'Ifurnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them .Vefore."putting the.-well in use. The above <br /> information is true to the best of tmy. knowledge -and-belief. I WILL CALL FOR A GROUT INSPECTION <br />', PRIOR TO GROU G ANIS A FINAL IN PECTION <br /> of��_ <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT -USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7-1? <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAy4f�n/FINU INSPECTION <br /> INSPECTION BY DATE INSPECTION DAT <br /> ]677- 9n�r <br />