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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE,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 Issued // _7/- <br /> (Complete In Triplicate) o t 5_(3 U -( ,? <br /> Application is her'Ciy 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 .Toaquiri: <br /> County Ordinance•No:. 1862 aad` the Rules and Regulations of the San Joaquin Local Health District. <br /> t�ZS E tni��.. . S7 e SUS TRACT <br /> JOB ADDRESS/LOCATION C. <br /> Phone <br /> Owner's Naive <br /> i 9 <br /> Address City <br /> Contractor's Name <br /> ID License , Phond_9 �.� <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN RECONDITION /? DESTRUCTION <br /> k PUMP INSTALLATION/ / PUMP,.REPAIR 5'' PUMP REPLACEMENT �T <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> iSEWAGE DISPOSAL FIELD CESSPOOL/1 .SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PUBLIC DOMESTIC WELL'— PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial A Cable Tool'N i Dia. of We11�Excavation <br /> Dome stic/private #T Dri3led J Dia. of .Well Casing- <br /> Domestic/public Driven Gauge of Casing <br /> j' Irrigation H Gravel. Pack. Depth of Grout Seal <br /> Cathodic Protection __:_ Rotary Type of Grout ' <br /> Disposal Other Other Information ' <br /> p Surface Seal Installed B <br /> Geophysical t <br /> CATION: Contractor <br /> i PUMP INSTAL � H.P. <br /> Type: of Pump <br /> PUMP REPLACEMENT: . / / State Work Done <br /> r t <br /> PUMP ,.REPAIR: �Ar `State Work Done <br /> i Approximate Depth _ <br /> DESTRUCTION OF -WELL: ' Well Diameter <br /> Describe 'Material,and Procedure <br /> 4r. - - <br /> I hereby agree�toTcomply with all laws and regulations of the 'San Joaquin Local Health District <br /> 'sand the State of California pertaining to or regulating well'-construction. Within FIFTEEN DAYS <br /> i of ter completion of my work.lon a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the'1Well and notify them before putting the..well. in.use... .The above <br /> information is t e to the t of my,.kno dge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTI AN b A FI INSPECTI <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> OP <br /> FO DEPARTMENT USE ONLY <br /> PHASE I .�„ ; DATE /� r <br /> APPLICATION ACCEPTED BY f } <br /> ` ADDITIONAL COMMENTS: <br /> PHASE II GRpUT INSPECTI �PHAS�E�-I�,• I P.NAL INSPECTION <br /> INSPECTION BY . • DATE :INSPECTION BY r ._ DATE -,l ►' <br /> r <br />