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FOR OFFICE USE: SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> 1602 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2 <br /> THIS PERMIT EXPIRES 1YEAR FROM DATE ISSUED Date Issued <br /> � ' �� <br /> Application is hereb i (Complete In Triplicate) <br /> Y made 'to the San Joaquin Local Health District for a <br /> and/or install the work herein described. <br /> County Ordinance No. 1862 and the Rules andTRegulations of the San JoaquinPermit to construct <br /> his PPlication is made in compliance with San .7oaqui� <br /> JOB ADDRESS/LOCATION Local Health District. <br /> Ss .. X <br /> Owner's Name CENSUS TRACT <br /> P <br /> 4 <br /> Address S k Phone "v <br /> Contractor's Name T City <br /> License phoneme <br /> TYPE OF WORK (Check) : NEW WELL <br /> k /_7 DEEPEN / / RECONDITION / / DESTRUCTION /_ <br /> PUMP :INSTALLATION WPUMP REPAIR ~ <br /> Other. / / /./ PUMP REPLACEMENT 1-7 <br /> � P <br /> E DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY <br /> --SEWAGE­ DISPOSAL-FTELD= <br /> --PROPERTY-*LINE -a = CESS OP OL/SEEPAGE_PIT <br /> INTENDED USE PRIVATE DOMESTIC WELL, "`�T�R —�._, <br /> TYPE OF WELL PUBLIC DOMESTIC WELL <br /> IndustrialCable Tool 'CONSTRUCTION SPECIFICATIONS <br /> Domestic/private Dia. of Well Excavation <br /> Domestic _. Drilled Dia. of Well Casing �I <br /> /public, Driven <br /> Irrigation, $.' �- Gauge of Casing <br /> 'dravel Pack <br /> `' _ .Cathodic Protection # t Depth of Grout Sear G <br /> Disposal:' . -��'Ro"tary Type of Grout <br /> Geophysical —� Other Other Information 1 <br /> Surface Seal Installed B <br /> PUMP INSTALLATION: Wz- <br /> Contractor . <br /> ti- <br /> Type V <br /> .of Pump <br /> PUMP REPLACEMENT: H•P• <br /> fi 4 <br /> State Work Done > <br /> PUMP .REPAIR: IA/ f.— � <br /> MS State_Work Done r <br /> DESTRUCTION OF WELL,: Well` Diameter s <br /> Dascribe Material Approximate Depth <br /> '° ; and Procedure <br /> I hereby agree to comply.with all laws and re u <br /> and the State of California pe'rtainzng to or regulating .vell -construc <br /> g lations of the San Joaquin Local Health District <br /> after completion of my work on a new well, I will furnish the San Joaquin Local H <br /> WELL DRILLERS REPORT of the well and notify them before h the the -well tion. Within FIFTEEN DAYS <br /> information is true to the-best of my..ltnowled a and belief, Health District a <br /> Putting e well in use. The above <br />'RIOR TO GR TING D FINAL INSPECTION. g I WILL CALL F R A GROUT INSPECTION <br /> iIGNED <br /> TITLE <br /> D i <br /> W PL' T' PLAN ON REVERSE SID <br />'RASE I FOR DEPARTMENT USE ONLY IT <br /> FP ATION ACCEPTED BY �y <br /> DDDITIONAL COMMENTS: DATE O <br /> PHASE II aRnTM INS 'ECTION <br /> NSPECTION BX DATE P / INSPECTION ! <br /> .INSPECTION BX ATE <br /> E H 1426 'f <br /> Rev. '1-74 , <br />