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SAN JOAQUIN LOCAL HEALTH DISTRICT I k?o14_1 <br /> FOF OFFICE USE: 1501 E. Hazelton Ave., .Stockton, Calif. - -/:` <br /> Telephone-. (209) 466=678.1 7 a;z� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMT Permit No. 17 <br /> THIS PERMIT E}�'IRES 1 YEAR FROM DATE ISSUER Date Issued %� 7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for .a permit to tox�struct <br /> and/or install the work herein described. This .application is made in.. compliance with San JOaguini <br /> County Ordinance No. 1$5.2 and 'the Rules and Regulations of the San Joaquin Local Health District. <br /> 30B ADDRESS/LOCATION Q � � <br /> CENSUS TRACT' <br /> 01 <br /> Owners Name <br /> Phone <br /> Address C> City <br /> Contractor s Name License �S^� 'hone, � �f <br /> Cfnt - <br /> f <br /> TYPE OF_WORK.,s(Check)-: NEW WELL J EPEN "1 I cc�NDi �N .I_% DESUCTIaN / <br /> PUMP INSTALLATION 1r=j-� REPAIR .!1 PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK;1DD SEWER LINES Co PIT -PRIVY 'A - <br /> SEWAGE DISPOSAL FIELD;` CESSPOOL/SEEPAGE �PIT. OTHER <br /> }, <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTTC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> .Industrial ICable Tool Dia. of Well Excavation \ <br /> /'Domestic/private !Drilled Dia.-..of-Well Casing , 4 <br /> Domestic/public t Driven Gauge of Casing42 <br /> Irrigation rave Paek Depth;of Grout Seal Q ` <br /> Cathodic-Protection Notaryr Type of Grout EeiaQ <br /> Disposal �• {ether � Other Information <br />` Geophysica3 _ ''i ,! =-r + "" Surface :Seal�Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> hype of F H.P. ' _ <br /> POW"REPLACEMENT: f / Iqtate Work Done <br /> rPUMP :REPAIR: / /.. State .Work Done <br /> 'LDES•TRUCTION OF WELL: Well Diameter Approximate Depth _-- <br /> Describe Material and Procedure <br /> sT hereby agree to comply with all lams and regulations of the Saga 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 <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 GRD TIN D A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE-SIDE) . <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATIQN ACCEPTED BY DATE <br /> . ADDITIONAL COMMENTS: <br /> - PHASE TT G OUT INSPECTION PHASE ]CIT FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> b/7-7 <br /> r R 1426 RPv_ . 1-74 <br />