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_ SAN.JOAQUIN LOCAL HEALTH DISTRICT <br /> FOk 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 <br /> (Complete In Triplicate) <br /> Application is Aereby made to the San Joaquin Local Health District for a permit to construct r <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1_$62 and the Rules and Regulations of the San Joaquin Local Health Diptrict. <br /> JOB ADDRESSAOCATION 114k g SA N TA FE CENSUS .TRACT � <br /> Owner's Name Phone. `-•� <br /> AddressE <br /> city i!!: <br /> Contractor's Name � a� ,r4 <br /> j License #��� Phone <br /> r � . <br /> i <br /> TYPE OF WORK (Check) : NEW-WELL. /_7 DEEPEN /_7 RECONDITION /7 DESTRUCTION /7` <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMWT /. <br /> other <br /> DISTANCE TO NEAREST ASEPTIC TANK SEWER LINES PIT 'PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOLSEEPAGE 'PIT OTHER. <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL.- A 'jPUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ,Industrial Cable Tool Dia.' of Well Excavation <br /> .Domes3c/private^ ., X ; j jl'WDrilled Dia. <br /> Domestic/public Driven Gauge of Casing `. <br /> . ` A �, > . <br /> Irrigatioin - Gravel Pack Depth of Grout Seal <br /> -Cathodic Pro t�c,tion 1 :, . Rotary Type of Grout <br /> ,,.. . f <br /> Disposal Other (ether Information' <br /> Geophysical Surface Seal Installed By: v � <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: . / State Work Done ' Q Ci.�) y✓ Af jj <br /> PUMP -.REPAIR: /% State Work Done 31 � <br /> DESTRUCTIONOF WELL:. Well Diameter Approximate Depth ' <br /> Describe Material and Procedure <br /> . h <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating-well ''construction. Within FIFTEEN DAY$ <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 GROU G D F NAL. INSPECTION. <br /> SIGNED; TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II /FINAL ''INSPE it <br /> INSPECTION BY I I WDATE INSPECTION BY& DATE <br />