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(�� SAN JOAQUIN LOCAL HEALTH DISTRICT rr <br /> FOE OFFICE USE: 1GJ1 E. Hazelton Ave. , Stockton, Calif. s <br /> Teiephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete. In Triplicate) <br /> Application is hereby made to the San Joaquin Locai Health District for a permit to construct <br /> 3 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 /> y hu�t -,,jLLa.C$DiSUS TRACT <br /> s:.. JOB ADDRESS/LOCAT ON mss. <br /> Owner's Name .tw r -c., Phone <br /> Address L / G City <br /> License U PI-one <br /> Contractors Name <br /> i. <br /> 4 ; <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN / / RECONDITION /_7 DESTRUCTION <br /> PUMP INSTLATION PUMP REPAIR /� PUMP REPLACEMENT <br /> AL <br /> Otaer <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESPIT PRIVY ;} <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER } <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELL <br /> fi INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool _ Dia. of1We11 Excavation <br /> .r Domestic/private - illed Dia. of(Well Casing <br /> Driven - ----Gauge of Casing- <br /> ­ <br /> Irrigation <br /> asing- \' <br /> Irrigation Gr" el Pack Depth of Grout Seal <br /> Cathodic Protection ;y— Rotary Type of�Grout <br /> Disposal .. I -' _ Other Other Information <br /> Geophysical Surf ce*Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> T,'. . Type of Pump <br /> PUMP REPLACEMENT: /. State Work Done 0,�c� <br /> PUMP REPAIR_: State Work Done <br /> t <br /> j' DESTRUCTION OF WELL: Well Diameter I Approximate Depth ' <br /> Describe Material and Procedure <br /> Y laws and regulations of the San Joaquin Local Health District <br /> I hereby agree to comply with all Y, <br /> and the State of California pertaining to or regulating we�l'construction. Within FIFTEEN DAYS <br /> after cor:pletion of my work on anew well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify then before pu ting the well in use. The above <br /> information is true to the best of my knowledge and be]-ief I WILL CALL FOR A GROUT INRPECTION „ <br /> PRIOR TO GROU I G D LN Z INSPECT ON. <br /> SIGNED TITLE {�(/ <br /> j RAW PLOT PLAN ON REVERSE SIDE)— <br /> FOR DEPARTMENT USE ONLY <br /> PaASE I - DATE <br /> APPLICATION ACCEPTED BY �TFCT10 <br /> ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> PHASE II GROU // <br /> INSPECTION BY DATE INSPECTION BY i •�• DLTE <br /> 3/76 2M <br /> F i3 1426 Rev. 1-74 4 "# <br /> dh <br />