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( )AN JOAQUIN LOCAL HEALTH DISTR� <br /> FOE OFFICE USE: 1bO? E. Hazelton, Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP !POP. <br /> it No. 7,7-1,9 ,1a <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Dat ', Issued <br /> Z:C <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 /> a <br /> JOB ADDRESS/LOCATION I11, CENSUS TRACT <br /> Owner's Name <br /> Phone3 r 3 <br /> Address City ��� <br /> j Contractor's Name License #/4,1,343 Phone3� <br /> 'I <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN -/—/ RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION/% PUMP REPAIR /? <br /> �d PUMP REPLACEMENT /-7 <br /> Other I 1/_7 <br /> 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE 'PISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private i Drilled Dia. of Well Casing <br /> Domestic/public I Driven Gauge of Casing (� <br /> Irrigation I Gravel Pack Depth of Grout Seal <br /> Cathodic Protection I Rotary Type of Grout <br /> Disposal I Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. -L0 <br /> PUMP REPLACEMENT. /_7 State Worst Done <br /> PUMP .REPAIR: <br /> 1 State Work DoneME" <br /> - <br /> . ' I <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> .� I <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 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 /> PRIOR TO GROUTIA AND A YWAL INSPE ION. <br /> SIGNED TITLE i <br /> l RAW PLOT PLAN 'ON RE ERSE SIDE) 9 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: i _ } <br /> PHASE II GROUT INSPECTIO PHASE IIi,JFINAL INSPECTION <br /> INSPECTION BY DACE INSPECTION BYY/ <br /> !�/_ DATE <br /> o MG nxr <br />