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• S <br /> _ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO—E"OFFICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 , 1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �w <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> A , <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 andrthe Rules and Regulations of the San -Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION pL" a CENSUS TRACT <br /> Owner's Name Phone <br /> Address .a�` <br /> City�r Vie¢ <br /> Contractor's Name, L L <br /> License Phone^� �-- <br /> #� p /4y' ,!;-.?9t2 <br /> TYPE OF WORK (Check): NEW WELL/71—ID-EEPEN -/-7 RECONDITION f7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PCTMP REPAIR /`7 PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC ,TANK QA-t 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 <br /> }� Industrial <br /> " _�Eable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing 4 <br /> Domestic/public.- :: -.Driven. Gauge of Casing (} <br /> rrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout C <br /> Disposal Other . Other Information <br /> Geophysical <br /> Surface Seal Installed By: Are <br /> PUMP INSTALLATION: Contractor / j <br /> Type .of Pump r, H.P. <br /> _ <br /> PUMP REPLACEMENT: ' <br /> State Work Done;N <br /> PUMP.,:REPAIR: l <br /> / / -State Work Done <br /> DESdTRUCTION OF WELL . Well Diameter 3 ' Approximate Depth <br /> Describe Material and^-Procedure <br /> I hereby agree to comply with all laws and regulations of the Sart 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 D FINAI, INSPEOUGNO 4 ; <br /> SIGNED TITLE f gg <br /> (DRAW PLOT PLAN ON REVERSE SIDE 3 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE i <br /> APPLICATION' ACCEPTED BY <br /> DATE F. <br /> ADDITIONAL COMMENTS: <br />• ,, PHASE II GROUT INSPECTION S - __ PHASE INSPECTION NE <br /> INSPECTION BY DATE - INSPECTION BY DATE /..2-" ae" <br /> r <br /> E;,H 1426 <br /> c+j 1 �?� 9M f <br /> � '`�Rev..`.1-74--��.��� _. w _ <br />