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/' SAN JOAQUIN LOCAL HEALTH DISTRICT .� k <br /> FOP OFFICE USE: ' 1601 E. Hazelton Ave. , ,Stockton, Calif. <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 Issued17- <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. 186.2 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESSAOCATION X��/ ��� CENSUS TRACT ' <br /> Owner's Name % Phone <br /> Address ;Ile 14/V filD City <br /> Contractor's Name XA v' 1/? License # ZbP,2 Phone ��.?-67T1`'7 . <br /> TYPE OF WORK-" (Check) : NEW WELL / / DEEPEN /_% RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /? <br /> 0 ther <br /> DISTANCE TO NEAREST: SEPTIC TANK126- <br /> t. SEWER LINES PIT PRIVY <br /> e 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/publi_p Driven Gauge of Casing <br /> Irrigation IGravel Pack Depth of Grout Seal �Z <br /> Cathodic ProtectionRotary <br /> Type of Grout NI�4N/T <br /> Disposal :T�Other Other Information' <br /> Geophysical _ Surface Seal. Installed By: <br /> PUMP INSTALLATION: Contractor ' <br /> �,. Type 'of Pump H. <br /> Y � T � <br /> PUMP REPLACEMENT: / / State_Work Dane <br /> PUMP .REPAIR: /7/ State Work Done <br /> ... <br /> DESTRUCTION OF WELL; Well Diameter ---- ----....-Approximate Depth <br /> Describe Material and Procedure <br /> I •hereby agree to�-comply with all- Paws and regulations of the San Joaquin Local Health District <br /> and the State of California -pertaining to or regulating well "cons•truction. Within FIFTEEN DAYS <br /> after completion of:, my- work`on a new well, I will furnish the- San Joaquin Local Health District a 4 <br /> WELL DRILLERS REPORT of the well and'notify them before ^putting -th.'e well-in-`use. The above <br /> information is true to the best of. my knowledgeand',belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO OUTING FINAL INSPECTION. ; <br /> SIGNED TITLE ^� <br /> (DRAW PLOT PLAN ON REVERSE SIDE •� f <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> ,; , <br /> APPLICATION ACCEPTED BY DATE � a 77 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE �'_C y7 " INSPECTION BY (� DATE 54`�- <br /> N <br /> E H 1426 Rev. 1-74 117.7 77. ,: " 2M <br />