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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 9 16p1-E. Hazelton"Ave. , Stockton, Calif. <br /> Telephone ; (209) 466-6781 7,,7- <br /> r APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMITPermit No <br /> ,77 5�7 <br /> 3,THIS: PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued <br /> (Complete In firiplicate) 0S'9'_1�'0�-02 <br /> Application is her made .to .the Sam 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 JoaquTr <br /> r County Ordinance No i862 `and the Rules and Regulations of the San Joaquin Localth District. <br /> ilao'� i✓ <br /> JOB ADDRESS/Lol Heal!?lv r?,s <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone �� (1 'L/6"? <br /> Address' <br /> S/ fi3 S' city <br /> Contractor's Name elf, <br /> ,. •. <br /> License # Phone <br /> TYPE E-WORK:. Check-):� � �,_. � :° , . �' �.�. � � '•..^-�-r=_.,-== rs.., <br /> s , j NEW=WELL: x= /� <br /> /' 'DEEPEN`/ RECONDITION / / DESIRUCTIO <br /> PUMP INS ALLATION U�yp REPAIR / / PUMP REPLACEMENT /� <br /> Other / / -- <br /> - O <br /> DISTANCE TO NEAREST: SEPTIC TANK r 07p SEWER LINE F V� <br /> SEWAGE DISPOSAL FIELD PIT PRIVY. <br /> PROPERTY E PIT OTHER <br /> LINE'-- PRIVATE DOMESTIC WEOLL/SEEP PUBLIC DOMESTIC WELL— <br /> INTENDED <br /> USE TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> Ck <br /> Cab Tool Dia, of Well Excavation ! <br /> Domestic/private Drilled Dia, of Well Casing �f <br /> Domestic/public _ Driven . Gauge of Casing <br /> Irrigation a ck,, . - -A- <br /> Gravel".'bDepth of Grout 4a� ' <br /> Cathodic-Protection Rotary Type of Grout <br /> Disposal Other t Other Information <br /> —_- Geophysical Surface Seal Installed BY: r1 <br />-PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> "Z.. H.P. - <br /> PUMP REPLACEMENT: /.:./ State Work Done , <br /> PUMP .REPAIR: /7. / State Work Done <br />.:DES:TRT.CTr''ON 1 Diameter' ,.. <br /> Approximate' Depth <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 weil "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 ray knowledge and belief, I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO T AND. NAL INSPE , N. �# t <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: -- <br /> PHASE II GROUT-;INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ' <br />'1 E H 1426 <br />