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JOAQUIN LOCAL HEALTH DISTRICn <br />FOR OFFICE USE: 160_-E. Hazelton Ave., Stockton, Ca�_f. �r <br />i! • Telephone: P (209) 466-6781 <br />u <br />APPLICATION FOR WELL CONSTRUCTION -OR PUMP PERMIT Permit No. <br />THIS PERMIT,. <br />EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /�� '/�� <br />.Application is hereby made to the San (JoapuineLocal zHealth <br />District) � <br />ct <br />sand/or install the work herein described.q This applicationismade inrcomplianceermit twithnSanuJo <br />,County Ordinance No. 1862 and the Rules a e uP aqui' <br />g 114tions 5the San Joaquin Local Health District. <br />JOB ADDRESS/JWATION i <br />!Owner's N <br />Address <br />'Contractor's Name <br />c <br />'r CENSUS TRACT <br />Phone <br />Cit <br />License q2-331hon <br />'TYPE OF WORK (Check): <br />NEW WELL / / DEEPEN'/`/ <br />RECONDITION /_/ DESTRUCTION /_7 <br />PUMP INSTALLATION / / <br />PUMP REPAIR /—/ PUMP REPLACEMENT / <br />Other / <br />DISTANCE TO NEAREST: <br />SEPTIC TANK S PIT PRIVY <br />LINECESSPOOL/SEEPAGE <br />SEWAGE DISPOSAL.FIELDWER <br />PIT OTHER <br />INTENDED USE <br />PROPERTY LINE - PRIVATE <br />TYPE OF <br />DOMESTIC WELL PUBLIC DOMESTIC WELL <br />Industrial <br />WELL <br />CONSTRUCTION SPECIFICATIONS <br />Domestic/private <br />Cable Tool <br />Dia. of Well Excavation <br />Domestic/public <br />Drilled <br />Dia, of Well Casing <br />IrrigationGauge <br />Driven <br />of Casing <br />Gravel Pack <br />Cathodic Protection Rotary <br />Depth of Grout Seal <br />Type <br />Disposal <br />Other <br />of -Grout <br />\\\ <br />Geophysical <br />Other Information <br />1 <br />Surface Seal Installed BY: <br />PUMP INSTALLATION: <br />Contractor <br />Type of Pump <br />H.P. <br />1 <br />PUMP REPLACEMENT:State <br />State Work D <br />PUMP '.REPAIR: <br />State Work Done <br />)ES•TRUCTTON OF WELL: <br />Well Diameter. <br />Approximate Depth <br />Describe Material and Procedure <br />L hereby agree .to comply with all laws and regulations of the San Joaquin Local Health District <br />ind the State of California pertaining to or regulating well"construction. Within FIFTEEN DAYS <br />kfter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br />JELL DRILLERS REPORT of the well and notify them before putting.the..well in use. The above <br />reformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />RIOR TO GROUTING AND A FINAL INSPECTION. <br />SIGNED /1 1A n n <br />'HASE ' I <br />1PPLICATION ACCEPTED <br />DDITIONAL COMMENTS; <br />PHASE II <br />NSPECTION BX <br />BY <br />GROUT I—NS—P—EECTION <br />DATE <br />TITLE <br />PLOT PLAN ON REVERSE SI <br />FO� DEPARTMENT USE ONLY <br />INSPECTION BY <br />DATE OWI.-© %a 6J/.r'I}, <br />I/ -FINAL NALINSPECTON <br />//ATEI <br />1 /77 : 9M <br />