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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i FOF�:OFFICE USE: 3601 E. Hazelton;Ave. , Stockton, Calif. ' <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELT, CONSTRUCTION OR PUMP PERMIT Permit No. 7LL�10 <br /> THIS PERMIT EXPIRES l YEAR FROM DATE -ISSUED <br /> Date Issued 2� <br /> A (Complete in Triplicate) <br /> pp3icatiori is liereby made to the San Joaquin Local Health District for a permit to construct <br /> . and/or install the work hereon described. This application is made in compliance with San Joaquin <br /> County Ordinanice� oto. "1862 and the Rules and Regulations of the San Joaquin Local, Health Distri <br /> ct <br /> JOB ADDRESS/LOCATION ,. <br /> Name "'- � <br /> CENSUS TRACT <br /> Owner's <br /> t <br /> I Phone j _ 20_� <br /> .Address.� Vi <br /> City . <br /> Contractor's Name' <br /> - License Z37jPhone , <br /> i <br /> TYPE OF WORK (Check): NEW WELL -/_7 DEEPEN '/? RECONDITION /_7 DESTRUCTION'/ <br /> PUMP INSTALLATION <br /> / / PUMP REPAIR PUMP REPLACEMENT /7 <br /> .. Ottie�r <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES - PIT PRIVY' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> OTHER <br /> PROPERTY LINE - PRIVA <br /> INTENDED SE TYPWELL DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> Industrial y \ i <br /> UE OF CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavatio <br /> Don C� <br /> Domestic/private 1 Drilled Dia. of Well Casing <br /> mestic/public - Driven a 1" <br /> Irrigation .` = Gauge of Casing <br /> Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 1 Rotary <br /> Disposal Type of Grout <br /> Other _ Other Information ' <br /> Geophysical Surface Seal Installed 'B <br /> PUMP INSTALLATION: Contractor <br /> Type o f, Pump <br /> ¢ H.P. <br /> PUMP REPLACEMEAIT: / / State Work Done <br /> PUMP :REPAIR: <br /> State WorhDone - <br /> DESTRUCTION OF. WELL: Well. Diameter <br /> n Describe Material and Procedure Approximate Depth <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 well construction. Within FIFTEEN DAYS <br /> after completion of my work on .a new well, I will. furnish the San Joaquin Local Health Distract 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 GROUT INSPECTION <br />'RIOR TO G OUTING'AND A FINAL INSPECTION. <br /> 3IGNEll <br /> � TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE g <br />'RASE I FOR DEPARTMENT USE ONLY I <br />�'P CATION ACCEPTED BY <br /> LDDITIONAL COMMENTS: DATE/S I <br /> PHASE II GROUT INSPECTION PHASE I FIN YNSP CTION <br /> INSPECTION BY DATE INSPECTION BY <br /> . <br /> Rev.t 1-74 <br />