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SAN JOAQUIN LOCAL, HEALTH DISTRICT <br /> FOL-. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> I Telephone: (209), 466-6781 <br /> I APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. D� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) 2o-CS <br /> Application is ;hereby made to <br /> `! the San Joaquin Local Health District for a permit to construct <br /> and/or installr'.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 /> s - .� � cam✓ /��J�'fNSUSJ <br /> JOB ADDRESS/LOCATION /,S flrQva1-- C,4) 1/7Gc)1,16" 0 G0cc3tZ Sl-kA TRACT ' <br /> Owner's Name Phone <br /> 4 <br /> k <br /> Address City �A�2 <br /> �! <br /> - License �� Phone <br /> Contractor's Name ,• <br /> TYPE OF WORK (Check) : NEW WELL"/ / DEEPEN / / 'RECONDITION- /-°//" DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR -PUMP REPLACEMENT / / -'- <br /> -i 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 I CONSTRUCTION SPECIFICATIONS_ (` <br /> Industrial 9 Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled ;Dia. of Well Casing <br /> Domestic/public Driven ", Gauge of Casing <br /> Irrigation I . Gravel Pack Depth of Grout Seal <br /> Cathodic ,Protection e[ Rotary Type of Grout <br /> Disposal ! I Other Other Information. <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - ----- H.P. <br /> _ H.. _ .. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work Done E Ge- 4.0�/(:u <br /> tS tjOeAel !u� <br /> DESTRUCTION OF..rWELL: Well Diameter Approximate Depth <br /> !! <br /> Describe Material and Procedure <br /> I hereby agree, to comply withlall 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 will 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 GROUTING AND A FINALIINSPWTION. <br /> SIGNED TITLE :;Qn Joaquin Pump Coo <br /> (DRAW PLOT PLAN ON REVERSE SIDE) 4457 <br /> i # FOR DEPARTMENT USE ONLY Lodi, California 95240 <br /> PHASE I I 1 <br /> APPLICATION ACCEPTED BY i �j DATE <br /> ADDITIONAL COMMENTS: I <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY DATE '� v <br /> i <br /> 2M <br />