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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ' F08,OFFICE USE. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ' y, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> Co ty Ord na c_ a No. 1862 a �the Ru.e and gulations� the n�oaquim Local H�t�District, <br /> cC a � <br /> JOB ADDRESS/LOCATI f fF iQ CENSUSRACT <br /> Owner's Name Phone.!;-.2 <br /> Address 4 City , <br /> Contractor's Name n <br /> License S'¢la Phone <br />` TYPE OF WORK (Check): - NEW WELL/ DEEPEN _RECONDITION CONDITION /? DESTRUCTION f7 <br /> PUMP INSTALLATION /_ PUMP REPAIR /� PUMP REPLACEMENT %T <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TAN �J . WER LINES T 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 t <br /> . atrial Cable Tool <br /> Dia. of Well Excavation f <br /> / , � <br /> Domestic/private Drilled Dia. of Well Casing C, <br /> �w._».__ Domestic/public Driven Gauge of_, Casing_, <br /> `> irrigation Gr el Pack Depth of Grout Se y 3 <br /> Cathodic Protection ,,,—R otary f., a Type o€ Grout c{ t <br /> Disposal ' Other ' � Other Information <br /> i Geophysical Surface Seal Installed By: <br /> f` <br /> 'Z <br /> PUMP INSTALLATION: Contractor <br /> Type of Pu � H-P. <br /> iUMP REPLACEMENT: / / State Work Done <br /> 't1MP '.REPAIR: / -7—State Work Done e ------ <br /> ES TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> � . I hereby agree to comply with all laws and regulations of thea-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,€urnish the San Joaquin Local Health District a <br /> i WELL DRILLERS REPORT of the well and notify them-before putting..the .well in use. The above <br /> inf Fkmation is true to the—best—of my .knowledge and-belief. I WILL CALL FOR A,GROUT INSPECTION <br /> PRIOR'W MUTING ANDAE 0 - <br /> 5IGNR—NTITLE <br /> W PLOT PLAN ON REVERSE SIDE <br /> -FOR DEPARTMENT USE ONLY <br /> P I 7 Zb <br /> APPLICATION ACCEPTED BY -f DATE <br /> _el COMMENTS: <br /> - I INSPECTIOIOU NSPECTIOP <br /> INSPECTION BY DATE INSPECTION BY jZ1DATE S <br /> -E H 1426 . Rev. 1'-x7'4 '" 1-74 2M . <br />