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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB(.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 herei s is app ca i i de in compliance with San Joaquin , <br /> County Ordnance No. 1862 and o Local Health District. <br /> 30B ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name � <br /> r- 5- .v .�. �' /* c . Phone <br /> Address ip PC, �� �, City <br /> Contractor's Name Licenser# Phone <br /> r <br /> TYPE OF WORK (Check): NEW WELL/ DEEPEN ' _ RECONDITION /? DESTRUCTION Jam'' <br /> UMP INSTALLATION /V // PUMP REPAIR / PUMP REPLACEMENT <br />! Other <br />- , DISTANCE TO NEAREST: SEPTIC TANK b SEWER LINES PIT PRIVY <br /> IK SEWAGE DISPOSAL FIELD CESSPOOL/.SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br />' INTENDED USE TYP& OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> .�� Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 46 <br /> Irrigation Gravel Pack Depth of Grout Seal �• <br /> _ Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> F Geophysical Surface Seal Installed.BY: CY=, _ Y� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. .„.. <br /> PUMP REPLACEMENT: <br />� f/ State Work Done <br /> PM .REPAIR: L7 State Work Done <br /> . I <br /> ES"TRUCTION OF WELL: Well Diameter Approximate Depth ;_;4<,3 _ <br /> Describe Material and Procedure <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 <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 AND A FINAL I SPECTION. <br /> SIGNED TITLE ��- •n- �4-� <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY7 <br /> DATE � '.�� - <br /> ADDITIONAL COMMENTS: / <br /> PHASE II R T INSPECTION PHASE AL INSPECT N <br />�'�IATSPBCTIQI,t Ry _ nems _ �1"1vcr+mrnsr MAL __--_ _ '= -__namIT --- - ---- -_- -�-� <br />