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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. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the Sten Joaquin Local 11calth District for a permit to construct <br /> rind/or install the work herein described. This application is made in compliance with San Joaquinf <br /> County Ordinance No. 1862 and the Rules and Regulations of the• San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 2 L16 d CENSUS TRACT <br /> Owner's Name V/9 Phone , <br /> Addresst <br /> / m ` City 'zE%fG/r7'p4l <br /> i <br /> Contractor's Name ( F License # '7Gciz Phone <br /> ;7 <br /> TYPE <br /> TYPE OF WORK (Check): NEW WELL ' DEEPEN17 7 RECONDITION /-7 DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other, r_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK ( SEWER, LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELDCESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL -� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> 'Industrial Cable Tool Dia. of Well-EkcavA£i6n - <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal D <br /> Cathodic Protection Rotary Type ,of_ Grout. <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed„ By: <br /> , _ <br /> PUMP INSTALLATION: Contractor _ <br /> --- U f ._� . ._ ___ <br /> r Type of- Pump ...,.. U_ H.P: 1 <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP ,REPAIR: / / State Work Done y <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all Yaws and regulations of the San Joaquin Local Health District <br />'And the State of California pertaining to or regulating we11 'construetion. 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:iri: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 /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> 1111TMENT USE ONLY <br /> PHASE I _4 <br /> ? l <br /> APPLICATION ACCEPTED BY / •/v - DATE �p { 5e-?r <br /> ADDITIONAL COMMENTS: - <br /> PHASE II GROT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE -(0- 75 INSPECTION BY l DATE .-W-,l <br />