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SAN JOAQUIN LOCAL HEALTH .DISTRICT <br /> FO&iOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> fTelephone: ,(209) 466-6781 <br /> 7L. ATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> S PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> I (Complete is Triplicate) <br /> Application is hereby made to tha San Joaquin Local llealth District for a permit to construct <br /> and/or,install the work herein described. This -app3:ication is made in compliance with San Joaquin <br /> County Ordinance No. 1862 aril the Rules and gegulations.of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION a �'r Y CENSUS TRACT <br /> a � <br /> Owner',s Name ` <br /> f,J1S <br /> . Phone <br /> Address - Cit ' <br /> 3 y 1�`') <br /> Contractor'a Namiej ' <br /> License Phone <br /> .� ,� :�. ..•.---.gym. -»..«t��---��"��-�.:�.,�. <br /> TYPE OF WORK .(Check): ,'NEW WELL J_7 DEEPEN '/_7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /_7 PUMP REPLACEMENT �( <br /> f Other!/ / <br /> DISTANCE TO NEAREST:- <br /> SEPTIC TANK SEWER- LINES PIT PRIVY <br /> SEWAGEfDISPOSAL�YIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ----PROPERTY LINE`--PRIVATE-DOMESTIC-WELL =t�_----PUBLIC-DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial t Cable Tool .. Dia. of Well Excavation <br /> Domestic/private Drilled Dia-: of Well Casing <br /> Domestic/public Driven Garage of Casing iv <br /> Irrigation Gravel Pack ` Depth of Grout Seal <br /> Cathodic Protection i Rotary Type of Grout <br /> Disposal Other Other Information <br /> GeophysicalSurface Seal Installed By: r <br /> •• f <br /> PUMP INSTALLATION: Contractor: <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT; s ' t <br /> State WorkoDone <br /> - <br /> • .7W�•,.� <br /> ES;TRUCTION OF WELL: Well Diameter <br /> t <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with;all laws and regulations of the San Joaquin Local Health District <br /> and the -State! of, Calif6rnia�pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion .of .my..work: fln 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 FORA GROUT INSPECTION + <br /> PRIOR TO G ING AND ALIINSPECTION. <br /> SIGNED TITLE <br /> .V (DRAW PLOT PLAN ON REVERSE SID <br /> PHASE I qy� ;% R DEP TMENT USE ONLY <br /> ,> <br /> APPLICATION ACCEP + <br /> ADDITIONAL` COMMENTS: L DATE Zzz <br /> ` PHASE. II GROUT INSPECTION <br /> PHO► AL INSPECTIO <br /> INSPECTION INSPECTION BY DATE <br /> f t 1bATE <br /> 7;>. <br /> OFF-97) <br /> . <br /> n , <br />