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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOH OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> T Permit No. <br /> APPLICATION FOR WCONSTRUCTION OR PUMP PERMI <br /> ELL' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) 2 S 1 <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 /> 'tf� �''�Jj� 33 1 -Z'-5�- 33 CENSUS TRACT <br /> JOB ADDRESS/LOCATION TiP <br /> Phone <br /> M Owner's Name .1 <br /> k Address y ` City <br /> Contractor's Name License # Phone 7 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/ / RECONDITION /7 DESTRUCTION /7 ` <br /> PUMP REPAIR /} <br /> PUMP`INSTALLATION PUMP REPLACEMENT 17 C <br /> .� �.. O their <br /> DISTANCE,-TO NEAREST: SEPTIC TANK ^t -SEWER LINES ;gpaPIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL'/SEEPAGE PIT -- OTHER 'Q f r„ <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL ' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS _ <br /> Cable Tool Dia. of Well Excavation <br /> Indu8trial - ,, <br /> " W'-Domestic/private F X Drilled Dia. of Well Casing <br /> F <br /> T}omestic/public Dfiveh Gauge of Casing <br /> ' <br /> k Irrigation Gravel ' ack Depth of Grout" Seal <br /> RotaryType of Grout - ' f <br /> Cathodic Protection - i <br /> "Disposal _ -- Other Other Information <br /> .Ceophysical <br /> S.urface Seal Installed By: <br /> PUMP INSTALLATION: Contractors _ _ C <br /> ..,. Type of Pump 'r; H.P. <br /> _ � E <br /> PUMP REPLACEMENT: // State Work Done <br /> PUMP .REPiAR:'T _ x/ State Work Done p ..._ ...�.. -.. <br /> DESTRUCTION OF WELL: Well Diameter .../ Approximate Depth , <br /> Describe Material,and Procedure <br /> I hereby'agree to comply with all lawsI-and regulations of the San'J.oaquin Local Health District <br /> and the State of California pertaining t:o or regulating well'coastr.uction. Within FIFTEEN DAYS <br /> after completion of my work on a new well; I will furnish the San Joaquin Local Health(District <br /> WELL DRILLERS REPORT of the well and notify them before putting the -well in use. The above <br /> st of my-knowledge and belief. /I WILL CALL FOR A GROUT,,INSPECTION <br /> information is true to the <br /> PRIOR TO Gl AND INSPECTION. <br /> t TITLE <br /> SIGNED { <br /> All" D W PL T PLAN ON RE EitSE SIDE). <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> -- DATE <br /> APPLICATION ACCEPTED B4_:�" ; . <br /> ADDITIONAL COMMENTS: r <br /> PHASE IIGROUTINSPECTION PHASE-III/ INAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY DAT <br /> t 2M <br /> E H 1426 Rev. 1-74 <br />