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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS.:OFFICE USE: 1601 E. Hazelton Ave. ,. Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <br /> I (Complete' In Triplicate) <br /> Application is hereby made to the San Joaquin Local 1lealth .Diatrict 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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> cG <br /> JOB ADDRESS/LOCATION . (vim e""rev- eaz � CC,,G✓ xwl" CENSUS TRACT <br /> r <br /> Owner Is Name r t Phone ' - 91A <br /> _ 1 <br /> Address 9 <br /> City . . <br /> Contractor's Name License #.;VD 7SV-Phone 446 r0 &g6 1 <br /> t <br /> ; 3 <br /> TYPE OF WORK (Check): NEW WELL4F DEEPEN JYp RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INST LATION / / PUMP REPAIR _7 PUMP REPLACEMENT /7 <br /> Other / & O LIC,e <br /> DISTANCE TO NEAREST SEPTIC TANKV SEWER LI ES PiT PRI <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL �t CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool. ' � � Dia. of Well Excavation \3 <br /> =Domestic/Priva-te � ~ �Dta�of. Well Casing �- E -- - <br /> Domestic/public, Driven Gauge of Casing <br /> Irrigation ' i w. Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout .� .'. <br /> Disposal OtherOther Information :_`' <br /> Geophysical i Surface Seal Installed .B <br /> PUMP INSTALLATION:Y - <br /> � Contractor , � <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / ( State Work Done <br /> PUMPiREPAIR: /7 :State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Descrilie Material and Procedure j { <br /> I' hereby agree to comply with all laws and regulations of the. San Joaquin Local Health District <br /> and the State of California- perta ningyto,.or regulating we11 •'coristruction. Within FIFTEEN DAYS <br /> after completion of my" work on anew well, I will furnish the San Joaquin Local Health District a I <br /> WELL`DRILLERS REPORT of the well and notify them before putting..the..well. in.use.. . ,The above I <br /> information is true to the,best of .my.knowledge and belief.°.i"I=.WTLL CALL FOR A GROUT INSPECTION ' <br /> PRIOR TO GR TING ANDA NAL INSPECTION. t } <br /> .. r� <br /> SIGNED TiTLE'r` t <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT' USE ONLY <br /> AP IPL CATION ACCEPTED BY � DATE <br /> ADDITIONAL. COMMENTS: - /-� �.,_':_. _ <br /> } PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY 13 DATE .'INS'PECTION BY DATE . /.. <br /> E H 1426. Rev. 1-7k f. <br /> •tic- }s/71� 9M a <br />