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/ AN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;(a. ,5.34r,1 <br /> THIS PPRMIT. EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby nade' ta 'the San Joaquin Local health District for a permit to-, construct , <br /> and/or install the work herein described. This application is bade -in coiipliance with San Joaquin <br />, County Ordinance No.. 1862 and the Rules and Regulations of .the San Joagiin LIocd! Health District. <br /> JOB ADDRESS/LOCATION <br /> "CENSUS TRACT <br /> Owner's-Name Phone <br /> Address f? _ �.. City . <br /> Contractor's Name License # Phone <br /> } <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN '/-7 RECONDITION._/f DEST-RRUCTTON f � <br /> '�'" P 7M�'-'INSTALLATION J / PUMP REPAIR '/7 PUMP REPLACEMENT I_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--D MESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 1 Cable Tool Dia. of Well Excavations <br /> Domestfc/private ; Drilled Dia, of Well Casing + �' <br /> Domestic/public Driven -'Gauge of Casing I _; <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> 1 <br /> Disposalo Other Other Information t <br /> Geophysical Surface Seal Installed 'B <br /> PUMP INSTALLATION: �_` Contractor <br /> .--_•Type'-of Pump._. t H.P. <br /> PUMP REPLACEMENT: • `� <br /> % /, State Work Done t <br /> PUMP..REPAIR: / k—Sta.te Work_Done <br /> ..E <br />,DESTRUCTION OF _WELL: Well Diameter Approximate Depth OUB <br /> Des cri a Mater al and Procedure <br /> �. <br /> I hereby agree to comply with all aws and regulations of the 'San Joaquin Local Health District <br /> and the State of California pertaining to or regulating'well ��construction. jWithin 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..we'll. in'use_... .The above <br /> information is_-truest�of ' knowledge-and-belief;:I=W1LL CALL--FOR A GROUT INSPECTION <br /> PRIOR TO RO T A AL I r CTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE TI GROUT INSPECTION PRA S II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> V. A 749 <br />