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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR 'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: . (209). 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. - -f <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 andAhe Rules and Regulations of ..the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION / a#,Sp �, p CENSUS TRACT <br /> Owner's Name j S Phone - !y <br /> I <br /> Address <br /> ' l� � p/ City l'�e <br /> Contractor's Name s License # 2 .ID% .'3.Phone_'ng,� - <br /> TYPE OF WORK (Check) : NEW WELL '/�f DEEPEN '/—/ RECONDITION / / DESTRUCTION /'7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: ASEPTIC TANK SEWER LINES /�_7`-PIT PRIVY. <br /> SEWAGE DISPOSAL RIELD / CESSPOOL/SEEPAGE PIT OTHER <br /> Ltl PROPERTY LIN MT ATE DOMESTIC WELL4.::�'_ PUBLIC DOMESTIC WELL- <br /> INTENDED <br /> ELL INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation " <br /> t/ Domestic/private Drilled Dia.. of Well Casing _�'-p�q �- S{^CK, 1 G0 (q <br /> Domestic/public Driven Gauge of Casing <br /> Q <br /> irV Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout e"Na"A-L <br /> Disposal Other Other Information <br />[_Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br />;PU P REPAIR: f / State Work Done <br /> IDESiRUCTION OF WELL: Well Diameter 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 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 GROUTING AND A FINAL INSPECTION. <br /> SIGNEDfee TITLE fl <br /> (DRAW PLOT PLAN ON REV ERSE •SIDE) i <br /> FOR TMENT- USE ONLY <br /> !PHASE I - <br /> APPLICATION ACCEPTED BY - DATE <br /> 'ADDITIONAL COMMENTS: <br /> PHA§§III CR9PT INSPECTION PHASE I FIN& INSPECTION , <br /> iINSPECTION EX INSPECTION BY DATE <br /> rl4z <br />