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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ' Telephone: (209). 466-6781 <br /> f APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '3D <br /> THIS PERMIT EXPIRES 1 YEAR FROM 'DATE ISSUED Date Issued '32 <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 /> i <br /> f JOB ADDRESS/LOCATION 303 z A 66&, CENSUS TRACT <br /> Owner's Name <br /> Phone g� C7 <br /> Address r� City <br /> Contractor's Dame p. � i.., c���V -- -- License #.2Phone y <br /> Wit RECONDITION <br /> TYPE OF WORK (Check) : --NEW WELL`S—/� rD_EEPN_/_/ RECONDITION /_f DESTRUCTION <br /> AL <br /> PUMP INSTLATION' f PUMP REPAIR / / PLiML? REPLACEMENT /� <br /> Other /% cj <br /> oc <br /> DISTANCE TO NEAREST: .SEPTIC TANK_, SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL P].BLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Ex avation _ <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing ; t <br /> Irrigation k Gravel ,Pack Depth,of Grout Steal <br /> i <br /> Cathodic Protection Rotary" '}'` -'-'Type -of Grout <br /> Disposal <br /> Geophysical (( Surface Seal Installed B . : <br /> PUMP INSTALLATION:`--.- -Contractor 2L& It' r <br /> '-----Type of Pump H.P. <br /> PUMP REPLACEMENT: i <br /> ,,, State`Work Done <br /> PUMP REPAIR: - State Work .Done <br /> DESTRUCTION 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 <br /> WELL DRILLERS REPORT of the well and notify them before putting thewell in use,. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL. FO A GROUT INSPECTION <br /> ` PRIOR TO GR ING AND AdINj INSPECTION. <br /> SS.GNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> t FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY -- <br /> k ADDITIONAL COMMENTS: <br /> PHASE II GR ': INSPECTION PHASE FIN NSPECTION <br /> i INSPECTION BY DATE INSPECTION BY ATE <br /> t 0!7..7 _ 2M <br />