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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR 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 //'4~ <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 Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the. San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT, <br /> Owner'sName Phone <br /> Address - 6 WEST Cit . <br /> y, <br /> Contractor's Name LL L_Eb 111 y HOUT License # CU Q 2 Phone F97 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION / / DES'T'RUCTION /7R <br /> _ <br /> PUMP INST ATION / / PUMP-REPAIR / / PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PRIVY <br /> 1 SEWAGE DISPOSAL FIELD CE POOL/SEEPAGE PIT OTHER <br /> PROPERTY LINT; - PRIVATE` DOMESTIC WELL _ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> -LIndustrial Cable Tool Dia. of Well Excavation � U <br /> ome stic/private „ Drilled Ery ,Dia..-of Well CasingrT _ IN <br /> } Domestic/public ! Driven Gauge of Casing d <br /> ' Irrigation 3 ravel Pack Depth of Grout Seal <br /> Cathodic Protection �otar Type ype of Grout <br /> Disposal - Other Other Information <br /> Geophysical ` Surface Seal Installed,.By: <br /> PUMP INSTALLATION: Contractor3Y.. <br /> Type of Pump s H.P. . <br /> PUMP REPLACEMENT: / / State. Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> 7,7 � ._. <br /> DESTRUCTION 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 /> 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 beforewputting.=the. well in use... The above <br /> informatio is true to the bestrof -my knowled"ge 'and-belief.- I-- CALL-CAL'L FOR A GROUT-INSPECTION <br /> PRIOR TO G ING FI INSP CTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE l Ada 7 <br /> ADDITIONAL COMMENTS: <br /> Pik <br /> E T GROUT INSPECTION PHAS INTI/FINAL INSPECTION <br /> INSPECTION BY �. DATE I �"�5` INSPECTION BY � i(•Y DATE <br /> E H 1426 Rev. , 1-74 0,<71 2M <br />