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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE SE: 1601 E. Hazelton Ave. , Stockton, Calif. - <br /> . Telephone: (209) 466-6781 <br /> . APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. /0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �, -� <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION . klCENSUS TRACT <br /> N (, " V <br /> Owner's Name AL4.1 Phone <br /> Address City ' <br /> r � <br /> Contractor's Name License #4 Phone 4� <br /> TYPE OF WORK (Cheep) : NEW WELL DEEPEN / / RECONDITION /_/ ' DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT 17 i. <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEIAGE P1 E`'T OTHER <br /> PROPERTY LINE - PRI ATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE _ TYPE OF WELL CONSTRUCTION SPECT ICATIONS f <br /> Industrial 1tToo1 Dia, of Well Excavation elk <br /> Domestic/private /(42Drilled Dia, of Well Casing 14f// <br /> D stic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout �- <br /> Disposal Other. Other Information <br /> Geophysical Surface Seal Installed By: .' <br /> PUMP INSTALLATION: Contractor <br /> - Type of Pump 1 H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR; / /, State Work Done <br /> DE RUCTION OF WELL: Well Diameter _ :_ }� <br /> _ -'Approximate Depth - <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 'pe�rtaining to or -regulating �ell'-construction. - Within. FIFTEEN DAYS <br /> 1. <br /> after completion of my work on a new well, I will furnish the San Joaquin Local HAIth District a <br /> WELL DRILLERS REPORT of 'the well, and notify them before putting the Wellin use. The above <br /> information is tr to the bestknowledge and belief. I WILL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTINqrAA4 A FI AL I IO ! <br /> SIGNED TITLE (�54 1 - 0— <br /> DRAW PL01 PLAN ON REVERSE SIDE <br /> FO DEPARTMENT USE ONLY <br /> PHASE I ' <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY /1:�2 DATE J- <br /> . 1177.., <br /> 1177. . 2M <br />