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G 0 A* /e 0 7V- 1601 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF%.OF CE USE: E., Hazelton .Ave. , .Stockton, Calif. , <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S 33 <br /> THIS PERMIT EXPIRES l 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 Rulers and Regulations of the San -Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION,.. <br /> � r CENSUS TRACT , <br /> Owner's Name r Phone ' <br />,Address z / 1 D%h !� 1 City ' <br /> s <br /> Contractor's NameLicense #� 22 J Phone 1►-- . <br /> TYPE OF WORK (Check) : NEW WELL.-/7 DEEPEN '/-7 RECONDITION /-7 DESTRUCTION %J <br /> PUMP INSTALLATION "/ / PUMP REPAIR /7 PUMP REPLACEMENT 17 <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC TANK ._ .SEWER LINES __— 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 <br /> Type of Pump H.P <br /> . <br />'PU)U�IitEPLACEMENT: / / '-State Work Done <br /> PUMP iumaw State Work Done <br /> bESTRUCTION OF WELL: Well Diameter 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'construction. Within FIFTEEN DAYS <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 o - my:kno dge nde f. I WILL CALL FOR A GROUT INSPECTION i <br /> PRIOR TO MUIINGAND A FINAL INSPECTIO <br /> SIGNED R <br /> aE42 {DRAW P REVERS SIDE <br /> PDK DEPARTMENT USE ONLY <br /> PHASE I -. �� <br /> APPLICATION ACCEPTED BY. DATE.-� � <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION i. <br /> INSPECTION BY DATE INSPECTION BY Al, DATE <br /> E H 1426 1teti. 1-7& _ < 1. 7< 9M <br />