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F Vr <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT f1' <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. z7-!,,5 <br /> { THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 27 <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 herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 a=rid the R nd Regulations of the San Joaquin Local Health District. <br /> r rC� ' C)- �u�' r CENSUS TRACT <br /> ' JOB ADDRESS/LOCAT <br /> r �} <br /> Owner's NameL- Phone <br /> Address j Cit <br /> Contractor's Name License Phod <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN ,/7 RECONDITION /7 DESTRUCTION /7 <br /> PUMPJINSTALLATION f-1 PUMP REPAIR/-7 PUMP REPLACEMENT <br /> Other /-7 <br /> I 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 S <br /> INTENDED USE ITYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private '# Drilled Dia. of: Well Casing <br /> i Domestic/public 1 Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> 3 Rota ,of. Grout <br /> Cathodic Protection ti Rotary � <br /> a <br /> Disposal Other Other Information '. ' <br /> Geophysical t Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type; of Pump. H.P. <br /> PUMP REPLACEMENT: . . State Work Done <br /> �hYv <br /> PUMP ,REPAIR: 'f'1aStaCe -Work Done <br /> DESTRUCTION OF .WELL.: Well Diameter Approximate Depth _ <br /> L Describe Material and Procedure <br /> , I hereby agree to comply with all laws and regulations of the Sari Soaquin 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 anew well, I will furnish the San Joaquin Local Health District <br /> IWELL 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 INSPECTION - <br /> i SIGNEDTITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE2- 2-27 <br /> ADDITIONAL COMMENTS: A <br /> PHASE II GROUT INSPECTION PHOZ I NAL INSPECT12 <br /> ]CNSPECTION BY '� DATE INSPECTION BY DATE <br />