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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICEt_, SE: Calif. <br /> F0 O 'b 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 Issued/v// <br /> (Complete In Triplicate) i <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 /> JOB ADDRESS/LOCATION CENSUS TRACT _ <br /> Owner's Name /� . ,� Phone <br /> Address <br /> ' �'S � City �S'�.Ga•,� - - I <br /> Contractor's Name a License Phone�� <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT /_ ; <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 C . <br /> Industrial Cable Tool Dia, of Well Excavation _ T\ <br /> Domestic/private Drilled Dia. of Well Casing 61 <br /> Domestic/public Driven ` Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal OtherOther Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> { <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 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 GROUT AND A F AL INSPECTION. 1 <br /> SIGNED TITLE. ! <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED BY , DATE lU-t ' <br /> ADDITIONAL COMMENTS: _ Ai <br /> PHASE II GROUT INSPECTION PHASE II/FIbkAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY DATE '7 <br /> ote <br /> ,, .,� <br />