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SAN JOAQUIN LOCAL .HEALTH- DISTRICT I� A t TO <br /> fOF OFFIF2 USE: 1601 E. .Hazelton Ave. , Stockton, Calif. U� , <br /> tom` _ Telephone: (209) 466-6781 <br /> 7 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date! Issued <br /> (Complete In Triplicate) -`fS-- ( ry`a <br /> Application is hereby made to the San Joaquin Local Health District for a permit to onstru <br /> and/or install the work herein described. This application is made in complia an Jo quite <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Loc 1 Health Distri t. <br /> JOB ADDRESS/LOCATION '� l�` � OE �1 pril CENSUS CT <br /> I <br /> Owner's Name eo -,,I- P4 Vr, 194 /&Ey Phone s <br /> AddressS 7 S f1 /PCity 9L`1Ij <br /> Contractor's Name 8R0 License d)3 Phone-! qg, a <br /> t <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /_/ RECONDITION /-7 DESTRUCTION/-7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> `Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES(0_0 d - PIT PRIVY 'C3 <br /> SEWAGE DISPOSAL FIELD`" CESSPOOL/SEEPAGE PTT 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 /> Domestic/private Drilled Dia. of Well Casing o . <br /> Domestic/public Driven' , Gauge of Casing ` <br /> Irrigation Gravel Pack Depth of Grout Seal V <br /> `Cathodic Protection Rotary Type of Grout _ <br /> 'Disposal <br /> Other 2 Other Information <br /> -Geophysical \'I Surface'Seal Installed By L-AA Ag k <br /> PUMP INSTALLATION: Contractor /yY � <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done t _ <br /> PUMP -.REPAIR: / / State Work Done <br />, DES-TRUCTION 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 /> sand 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 f my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR UTING ANDA P CTION. <br />, SIGNED TITLE <br /> - (DRAW PLOT-PLAN ON-REVERSE "SIDE) _ <br /> R� DEPARTMENT USE ONLY <br />' PHASE 1 , <br /> APPLICATION ACCEPTED BY �® \. DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION �J PHASE I/FINAL INSPECTI N <br /> INSPECTION BY DATE /u INSPECTION B DATE <br />