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..M A SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOR,OFFICE USE: 1601 'E. Hazelton Ave. , ,Stockton, Calif. <br /> I� Telephone: (209) 466-6781 <br /> �M APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. W <br /> (11p-7 THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ,� (Complete In Triplicate) <br /> Application is "'hereby made to theSan Joaquin Local Health District for a permit to construct f <br /> andEVor install the work herein described. This application is,made in compliance with San Jo <br /> aquiny <br /> County Ordinance "No. 7862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> f <br /> JOB. ADDRESS/LOCATION 1 . - <br /> S'� CENSUS TRACT <br /> it Own�,er's Name s Phone <br /> AddressCit <br /> y <br /> Contractor's Name License # Phone - f <br /> i <br /> TYPE OF WORK (Check) : NEW WELDEEPEN / RECONDITION /^T DESTRUCTION /_7PUMP INST CATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 - <br /> DISTANCE TO NEAREST: SEPTIC TANK,'/am ¢ SEWER LINESID f PIT PRIVY <br /> tSEWAGE`DISPOSAL FFIELD CESSPOOL/SEEPAGE PIT OTHER 1 <br /> PROPERTY LINE"OPRIVATE DOMESTIC WEL Ma 4 puBLIC DOMESTIC .WELT, <br /> 1 INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> [, Industrial y Cable Tool Dia. of Well Excavation <br /> 11 Domestic/private ;Drilled Dia. of Well Casing 1211 <br /> 11 Domestic/public ;Driven Gauge of Casing <br /> Irrigation 1�Gravel Pack Depth of Grout Seal ,�.. <br /> II Cathodic Protection "Rotary Type of Grout <br /> I[ Disposal Other Other Information <br /> ,Iii Geophysical _ Surface Seal Installs By: - <br /> PUMP. INSTALLATION: <br /> y:PUMP. INSTALLATION: . Contractor ji � - <br /> 7i' Type of Pump H.P. <br /> _PUMP REPLACEMENT / / State'Work Done <br /> PUMP, ,REPAIR:. / / State„',Work Done t <br /> r: > <br /> DESS RUCTION OF WELL; Well Diametier Approximate Depth <br /> ., Describe_-Ma'terial and Procedure <br /> I hereby agree to comply withiall 'laws'arid regulations of ' the San Joaquin Local Health District <br /> anPthe State of California pertaining to_or .regulating�well 'construction.. Within -FIFTEEN DAYS <br /> after completion of my �Tork on- a_new­well,•-1--will-furnish the San.-Joaquin Local- Healtih District a ; <br /> WELLS DRILLERS' REPORT of`the'well and`noti y hem before putting the well in use. The above 1 <br /> inf rmation is true to the'' bes o y k w edge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO� U AN FINAL N CTI <br /> SIGNED TITLE L <br /> � (D � LOT PLAN ON REVERSE SIDE <br /> . FOR DEPARTMENT USE=ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED -BY IZ ` DATE / -;7 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P S II/F AL INSPECTION <br /> INSPECTION BY DATE X INSPECTION B DATE�2- <br /> L'1426 <br /> aEt,H..1426 Rev. 1-74 <br />