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. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB.OFFICE USE: 3601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: {209) 4b6-b781 _ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S - gyp <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 herein described. This application 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 ,:t;, G.t i E d� er g 'Aa&jg, v a;t- X /' .4),6P^,0W' CENSUS TRACT � <br /> Owner's Name ..S v 0. �t It, e( .T Phone <br /> Address 1 22" Cit <br /> f a y <br /> Contractor's Name License Phone it4a•2476, <br /> TYPE OF WORK (Check): NEW WELL './7 DEEPEN -/7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION %/ PUMP REPAIR /_7 PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMIESTIC WELL ' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> _- Domestic/private Drilled Dia. .of Well Casing N <br /> Domestic/public r Driven Gauge of Casing ti <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical. Surface Seal Installed. BY: <br /> PUMP INSTALLATION: Contractor &-xl <br /> Type.of Pump_. ,i in.s�-�'i H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .• �/ State Work Done <br /> OES•TRUCTION OF WELL: Well Diameter ; Approximate Depth <br /> Describe Material and `Procedure' <br /> ---- - <br /> I hereby agree to comply with all laws and regulat"ionis• of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating e�ell '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 GR UTING AND A FINAL IN PECTI N. <br /> SIGNED ` <br /> ITLE . <br /> (M FUMP-PLAI AkRSE SIDE) -"--- <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I E;a <br />-AP.PLICATION' ACCEPTED BY DATE ZS <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> -. r <br />