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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> j FOE OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> E Telephone: (209) 466-6.781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> zL (Complete In Triplicate) <br /> Application is Aereby- 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 /> 4 <br /> County- Ordinance-No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> tga" 9z <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone — 31 <br /> Address y 7 City <br /> Contractor's Name License Phone.� <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/—/ RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> A /? <br /> Other P/ -` <br /> DISTANCE TO NEAREST: SEPTIC ,TANK SEWER LINES PIT PRIVY ' <br /> PROPERTYLINEIAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE e'-x TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial g <br /> , .. Cable Tool Dia, of Well Excavation <br /> 1: Domestic/private Drilled Dia, of Well Casing , N <br /> I Domestic/public Driven <br /> IrrigationGauge of Casing <br /> k <br /> `p Gravel, Pack Depth of Grout Seal � <br /> Cathodic Protection # Rotary Type of Grout <br /> Disposal Other ,Other Information <br /> t <br /> Geophyscal ._ ..� .�..,�..,� Surf-ace By-: <br /> PUMP INSTALLATION: Contractor <br /> Type o`f Pump H.P. . . <br /> PUMP REPLACEMENT: / / State Work Done i} <br /> ! J_.3. 7 <br />' PUMP '.REPAIR: / / State Work Done 11 <br /> DESTRUCTION OF WELL: Well Diameteri <br /> Approximate Depth <br /> Describe Material and Procedure ' <br /> I hereby agree to comply withlall laws and regulations of the San Joaquin Lo'cal Health District <br /> sand the State of California pertaining to or regulating well "construction. Within FIFTEEN DAYS <br /> iafter completion of my work qn a new well, I will_furnish_the San Joaquin Local Health District a <br /> CWELL DRILLERS REPORT of the well and notify Chem before putting they 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 /> PRIOR TO G OUTING Amn A FINALIINSPECTION. <br /> SIGNED # TITLE <br /> i F (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> PPLICA <br /> ATION ACCEPTED BY DATE <br /> ADDITIONAL C091MENTS: n - — <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> ,E 1-74 H 14 2 6 4 Rev.. 1-�4 � �% .. .� �� �- 1 7.7 2M <br />