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` '•`- - SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ( FOP OFFICE USE: .� 1601 E. Hazelton Ave. , Stockton, Calif. / /V <br /> t �. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION. OR PUMP PERMIT Permit No. <br /> I <br /> i <br /> ' THIS PERMIT EXPIRES11 YEAR FROM DATE IS§1'JED Date Issued el;2/7 <br /> Application is hereby made to the San (JoaquineLocalin riflict <br /> H aq.thDiArict for a permit to construct <br /> and/or install the work herein described. This applicatiof' iFinade in compliance with San Joac <br /> County Ordinance No. 1862 and the Rules and Regulations of. ,the San Joaquin Local Health Distric <br /> JOB ADDRESS/LOCATION L /~ <br /> CENSUS TRACT ' <br /> Owner's Name <br /> . � l � Phone <br /> Address L' y W �.i <br /> h1 ilY � City <br /> Contractor's Name � � License hone��- <br /> TYPE OF WORK (Check): V NEW`WELL , <br /> J� DEEPEN f_% RECONDITION /� DESTRUCTION / 7 <br /> .Otho INSTALLATION /�/ PUMP REPAIR /% PUMP REPLACEMENT /7 <br /> Y Other %. / <br /> � A • <br /> DISTANCE TO NEAREST: SEPTIC TANK f PD. SEWER LINE!13 PIT PRIVY <br /> " 13 SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL ..— i,PU$LIC DOMESTIC WELL _ <br /> . ,INTENDED USE 'TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ,Industrial ! -X Cable Tool Dia. of Well Excavation 1 <br /> _X Domestic/private Drilled Dia. of Well—Cas.ing 'IS ---I <br /> Domestic/public } .. : ' Driven <br /> Gauge of Casing <br /> Irrigation " :( ---Gf&Vel(Pack Depth of Grout Seal <br /> Cathodic Protection •:,t...'•Rotar / <br /> �- <br /> .Disposal� y , Type of Grout '4 JY' <br /> . 'tOther Other Information <br /> Geophysical <br /> 3 Surface Seal Installed B <br /> PUMP INSTALLATION• Cohtracior" <br /> Type of,Pump 1 <br /> 5 �,.Qr_ke H.P. J <br /> PUMP REPLACEMENT: / / State Work Done I <br /> PUMP .REPAIR: <br /> StateWork—Done <br /> DESTRUCTION OF WELL: Well Diameter r Approximate Depth i <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 well1.,' I will furnish the San Joaquin Local Health District <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 G OUTING AND A FINAL IP7SPECTION. <br /> SIGNED TITLE yy�� <br /> (1��►n�n <br /> (DRAW' PLOT"PLAN' ON 'REVERSE"SIDE) <br /> PHASE I <br /> FOR DEPARTMENT-USE-ONLY <br /> APPLICATION ACCEPTED BY DATE of <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I FIN�JNSPECTION <br /> INSPECTION BY DATE INSPEEC N -BY <br />