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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO :*OFFICE USE: 1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,<- 641 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued ?e <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local )health District for a permit to construct <br /> and/or install the Work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION r CENSUS TRACT <br /> Owner's Name 0 Phone_ <br /> Address Rij City <br /> Contractor's Name i License # /2 j Phone <br /> TYPE OF.WORK._.(Check) : -NEW WELL.'/-7 -DEEPEN '/? /7-7. --DESTRUCTION <br /> RECONDITION /- =DESTRUCTION T <br /> PUMP INSTALLATION /� PUMP REPAIR-/-7-pump REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT 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 <br /> l Industrial Cable Tool- -Dia. of Well Excavation ( _ <br /> Domestic/private Drilled` } :, °, Dia. of Well..Casing W <br /> Domestic/public '. Driven. , Gauge of Casing <br /> Irrigation- Gravel Pack-l ' Depth of) Grout •Seal <br /> Cathodic Protection 9, . Rotary. Type of Grout <br /> Disposal ` Other Other Information ' <br /> j Geophysical Surface Seal Installed 'B : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter AP01 Approximate Depth _ 6 <br /> Describe Material and Procedure <br /> j I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> f 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 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 /> SPRIOR TO GROUTING -AND A FINAL INSPECTION. <br /> SIGNED 1 TITLE <br /> f (D 'LOT PLAN ON REVERSE SIDE <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PRASE II G SP ION PHA INSPECTION <br /> ' INSPECTION BY ATE INSPECTION BY DATE <br /> i <br /> 1./7q 9M <br />