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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F OFFICE USE: ' 1601 E. Hazelton Ave. , ,Stockton, Calif. ,' 3 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 4� THISI PERMIT EXPIRES '1 YEAR FROM DATE ISSUED Date Issued <br /> /� (Complete In Triplicate) <br /> Application is ► reby made to'( San Joaquin Local Health District for a: permit to construct' j <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. I� <br /> JOB ADDRESS/LOCATION �OC�� - ' .B Q CENSUS TRACT , t <br /> Owner's Name Phone 679,7- 802 <br /> I <br /> Address . - ,2 7 City <br /> �x <br /> Contractor's Name 'k License # M,3Phone �SS��f `� ! <br /> s <br /> TYPE OF WORK (Check) : NEW WELL' / 7 DEEPEN / / RECONDITION /_/ DESTRUCTION-•/-] <br /> PUMP INSTALLATION /, / PUMP REPAIR / /�,r-PUMP REPLACEMENT /7 j <br /> Other /�/ ".- _• - <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER. LIItsS PIT PRIVY <br /> .s SEWAGE DISPOSA•L"rF ELD:- CESSPOOL/SEEPAGE FIT OTHER' � { <br /> PROPERTY' NE_—PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE--� TYPE-OF WELL CONSTRUCTION SPECIFICATIONS i <br /> Industria71 Cable Tool Dia, of Well Excavation <br /> YDomltc/p.rivate 4 'Drilled .,. ��F�� Dia, of Well Casing <br /> ' <br /> Domestic/public Driven - ._.� 'Gauge of Casing <br />=/L-I rigation 1 Gravel Pack -Dep-th,,of:.,,Grout...Seal <br /> Cathodic Protectio Rotary Type ofKGrout- . <br /> Disposal - _Other Other Orher,Information --K-/ - <br /> Geophysical �':.. Sukface,ISeal Installed By: ,(' <br /> PUMP INSTALLATION:, Contractor "v <br /> Type.: of Fume` 4 H.P. <br /> PUMP REPLACEMENT: /-7 State Work Done I <br /> 1 Lg, x <br /> PUMP .REPAIR: / / tate Work Done X44 <br /> ESTRUCTION OF WELL: ©e mete proximate ept <br /> Describe Materi and cedure �s <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 f <br /> WELL DRILLERS REPORT of ,the well and notify them before putting the well in use. The above <br /> information is true to t`he -best•of my knowledge and belief. I WILL CALL FOR A GROUT_,INSPECTION <br /> PRIOR TO GROUTING AND A FINA INSP CTION. <br /> SIGNS TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) i <br /> OR DEPARTMENT USE ONLY i <br /> PHASE I r. ' <br /> APPLICATION ACCEPTED BY a DATE <br /> ADDITIONAL COMMENTS: " <br /> PHASE II GROUT? INSEECTION PHAIII/ NAL INSPECTION <br /> INSPECTION BY DATE, INSPECTION B DATE <br /> �r - f <br /> - - _ ��7 2 <br /> E H 1426 Rev. 1-74 ,�,. <br />