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__ N JOAQUIN LOCAL HEALTH DISTRIC' lu q <br /> F_Oh OFFICE USE: l0r E. Hazelton Ave. , Stockton, CaXf. <br /> Telephone : (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 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 /> JOB ADDRESS/LOCATION N3 �Cf S� � � �� Lo� CENSUS TRACT _ <br /> Owner's Name Phone <br /> Address S, N[6- City ESG.4G0. <br /> Contractor's Name OWIVJF� License # Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR / _/ PUMP REPLACEMENT -7 <br /> PUMP <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK /2 S SEWER LINES 1.2 ; PIT PRIVY _ <br /> SEWAGE DISPOSAL 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 Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor N R� --- <br /> Type of Pump �3 H.P. <br /> � <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> --__� <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> r <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 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 GROUTING AND ,4 FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I rDATE <br /> APP <br /> APPLICATION ACCEPTED BY _ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTICl/ PHASE /FIN INSPECTION <br /> INSPECTION BY DATE I V INSPECTION BY DATE _ 3 =7 7 <br />