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• SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ` .n Telephone : (209) + 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 1 <br /> THIS'PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �7 <br /> ' �, (Complete In Triplicate) <br /> Application''is 'h'ereby 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 <br /> oaquin {County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> . ...,;� 1 .. ,,. <br /> JOB ADDRESS/LOCATION �p e9 <br /> CENSUS TRACT <br /> 4 <br /> Owner's Name- a' <br /> Phone <br /> Address l ' <br /> C9 City <br /> Contractor's Name License Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION ./-7 ' DESTRUCTION /_7 <br /> PUMP INSTALLATION / / .PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 # Cable Tool Dia, of Well- Excavation 0 <br /> .,Domestic/private I Drilled t Dia, of We'll Casing <br /> K �. 4 '": <br /> Domestic C <br /> /public ! Driven tet_ .Gauge _of_. Casing _. a _ _ _ _ _ <br /> Irrigation I Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 1 Rotary Type of Grout 0 0 <br /> Disposal I Other Other Information <br /> Geophysical , Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type*of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done + <br /> PUMP .REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby .agree 'to comply- with all laws and regu.1ations of the San Joaquin Local Health' District <br /> and the State of California pertaining to or regulating well "construction. Within FIFTEEN DAYS r <br /> after completion of my work onla new well, I will furnish the San Joaquin Local Health District -a <br /> WELL DRILLERS REPORT bf 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 r <br />?RIOR TO GROUTIN AN FINAL INSPECTION. <br /> SIGNED TITLE <br /> d (DRAW PLO tPLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I n <br /> APPLICATION ACC tPTED BY /� DATE 7-/?-'7 7 <br /> ADDITIONAL COMMENTS: . ,1 a <br /> PHASE II GROUT INSPECTION - / P SE I/FIN INSPECTION <br /> INSPECTION BY DATE N INSPECTION BY ' DATE _ TJ <br /> 1 <br /> E H 1426 .� , _7 4 4 _ r /Z <br /> Rev. 1 7 2M , <br />