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FOF� T111601 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. Hazelton Ave. , Stockton, Calif. <br /> ,OFFICE USE: (209) 466-6781 <br /> : Telephone: � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> s <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued S, 13-7� j <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 /> �? US TRACT <br /> JOB ADDRESSAOCATION 7� Gly' =�� - CENSUS .. <br /> r Phone -q CZ-0 Z,Gf <br /> Owner's Name <br /> 'City <br /> Address q,,r,7- n &,d4 <br /> Contractor's Name License #ZOO?9 hone Qin <br /> TYPE OF WORK (Check)*. NEW WELL DEEPEN /7 RECONDITION f DESTRUCTION <br /> PUMP INSTALLATION �/ PUMP REPAIR./ PUMP REPLACEMENT I�T <br /> Other El <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 /> r INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Too!- Dia. of Well Excavation <br /> _ Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing.. v <br /> 4 Irrigation — Gravel Pack' Depth of Grout Seai 7,2 <br /> ► <br /> Type of Grout <br /> Cathodic Protection <br /> Rotaryydr Information <br /> Disposal Other <br /> Geophysical Surface Seal--Installed 'By,: <br /> r <br /> PUMP INSTALLATION: Contractor 1 �- -"" <br /> Type .of Pump H.P. <br /> PUMP;REPLACEMENT: , / / State Work Done <br /> PUMP ':REPAIR: /-7 State Work Done - <br /> N-1 , <br /> AESTRUCTION OF WELL: Well Diameter ; :�. Approximate Depth <br /> Describe Material. and Procedure ??tib. <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 comple�4on_'of my work on a new well, I will furnish the San Joaquin LocaltHealth' Distirict a <br /> WELL DRILLERS REPORT,of ttie well and notify them before putting. the..we11. in-uss._.. The above <br /> information.i_ s true,to the•best of- my`knowledge and_belief. . I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO TING AND ' INAL INSPECTION. <br /> i <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SI E <br /> . , <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: f fF <br /> PHASE II GROUT INSPECTION P PHASEIII FINAL INSPECTION <br /> INSPECTION BY 'DATE INSPECTION DATE �.1�?G _ <br /> h/75 2M <br />