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i <br /> ?OAQUIN LOCAL HEALTH DISTRICT <br /> F06.OFFICE USE; 1601 ' Hazelton Ave. , Stockton, Calif, � p <br />'E. Telephone: (209): 466-6781 p <br /> APPLICATION FOR WELL CONSTRUCTION ORIPUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDI Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to thelSan Joaquin Local Health District fora permit <br /> � .. p mit to construct <br />: .and/or instal,l .the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance. No. 1862 and thefRules and Regulations of the San Joaquin Local Health District. <br /> f,. <br /> fJOB ADDRESS/LOCATION Z22- S LL FGA CENSUS TRACT ' <br /> Owner's Name Phone 2S"�j!�� <br />' Address i City _ <br /> Contractor's Name G <br /> AI License #2-QO q Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN <br /> / / RECONDITION DESTRUCTION <br /> PUMP INSTALLATION I[.a1 ,POMP REPAIR / PUMP REPLACEMENT /- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK .', SEWER LINES - ,2g' " PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CES /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 /0// 4 <br /> Domestic/private Drilled Dia. of Well .Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation . 'Gravel Pack Depth of Grout Seal <br /> Cathodic Protection <br /> . _,�_ ;Rotary Type of Grout <br /> Disposal Other <br /> :Other Information <br /> Geophysical Surface Seal. Installed B : <br /> . <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump Z/vU G <br /> _ S L H.P. i <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth. <br /> Describe Material and Procedure <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-•cbnstruction. Within FIFTEEN DAIS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a 1 <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 ofi'my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION l <br />'RIOR TO GROU NG AND. A F AL INSP ION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE i <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY I <br /> ADDITIONAL COMMENTS: DATE ' <br /> P II G UT INSPECTION PHASE-III FINAL INSPECTION <br /> CNSPECTION BY DATE _� 1�-?� INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 - A ,177 opug 411 <br />