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SAN JOAQUIN LOCAL HEALTH-DISTRICT <br /> FOfi OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT' Permit No.7�zt) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUER ,( tA Issued3 -� <br /> (Complete In. Triplicate) <br /> Application is hereby made' to the San Joaquin Local Health District for a permhooonstruct <br /> and/or install the work herein described. This application•licatio <br /> n 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 /> JOB ADDRESS/LOCATION ZYS45V CENSUS TRACT <br /> Owner's Name Phone 6 <br /> Address . T City I <br /> Contractor's Name License #,�2 ? V jrPhone '� <br /> TYPE OF WORK (Check): NEW WELL -DEEPEN '/7 RECONDITION /7 DESTRUCTION /-7 ; <br /> PUMP INSTALLATION O PUMP REPAIR /7 PUMP REPLACEMENT % 7 <br /> Other.—/-7 <br /> DISTANCE_TO-NEAREST:- SEPTIC •TANK 3&V R SEWER LINES ., ,. `,PIT, PRIVY -� <br /> SEWAGE-i.DISPOSAL-FIELD - ----«--CESSPOOL~/SEEPAIiE"PIT' OTHER <br /> -- <br /> PROPERTY LINE PRIVATE.DOMESTIC WELL <br /> PUBLIC DOMESTIC WELL \ <br /> a �l <br /> `INTENDED USE t . TYPE OF WELL CONSTRUCTION SPECIFICATIONS..__ C.0 <br /> I dustrial a le Took. Dia. of Well Excavation <br /> _.Domestic/private Drilled. Dia. tof Well Casing }k Q <br /> Domestic ubd ---�;-n <br /> /.per �� � „Driven � Gauge of Casing e�. \ <br /> . F Irrigatiorix,; --- y Gravel Pack- Depth o£ Grout Seal <br /> ,-'Cathodic Protection, Rotary Type 'of Grout _ Pse-et;Disposa`1"' jOther Other Information <br /> Geophysical "_ + Surface Seal Installed B <br /> f.. <br /> PUMP.'ZNSTALLATION: Contractor : <br /> Type of Pump H.P. _ <br /> -Mi <br /> !�- <br /> PUMP''REPLACEMENT: , /-7 State Work Done f <br /> PUMP ,.REPAIR: / / State Work Done 1 <br />' DESTRUCTION OF WELL: .Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to coop y with all laws and regulations pf,%tho- Safitijo4quin-Local Health District <br /> and the State of Califoritia pertaiiiiing to or regulating.-we`ll construction. Within FIFTEEN DAYS { <br /> after completion,of my`work on anew well, I will furnish the San Joaquin Local Health District a <br /> .>. � , <br />` WELL DRILLERS REPORT of.�the.Well end xio-tifyW�hem before putting.th�rell in use.... The above =� <br /> ,.,�. .. , <br /> information is trueto the?'b--est aCnm;� nowiedge, and 'belief. I WILL CALL FOR A GROUT INSPECTION <br />-PRIOR TO'GROUTIN a D'A'F ,. I <br /> SITGNEDF ` s TITLE <br /> (DRAW PLOT PLAN ON REVERSE IDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ` <br /> ADDITI.O-P AL-COMmENTS: i <br /> �PHASE`Ij=G�IIT-INSPECT.ION PHASE III FINAL INSPECTION. <br /> INSPEL4ION .BY bA�T$ INSPECTION BY DATE f <br /> •y <br /> E H X1426 Rev ` <br /> t <br />