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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 79 OFF CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 'Telephone: (209) 466-6781 1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> f' THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued &I <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local stealth 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 kir CENSUS TRACT <br /> Owner's Name Phone <br /> Address <br /> pity .08'd� <br /> Contractor's Name Q License # Phone , <br /> TYPE OF WORK (Check): NEW WELL/_7 DEEPEN '/_7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR-/-7—pump REPLACEMENT <br /> Other / / . . . . . . . <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD _' CESSPOOL/.SEEPAGE PIT OTHER <br /> r= � <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS \� t <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing g <br /> Domestic/public Driven Gauge of Casing - E <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ' ' { { <br /> Geophysical x `Surface Seal Installed- BY: <br /> PUMP INSTALLATION. Contractor i- <br /> Type of Pump TY <br /> H.P. <br /> PUMP REPLACEMENT / State Work Done <br /> -Ld= =121 9 1,/ <br /> PUMP .REPAIR: / / State Work Dona <br /> DESTRUCTION OF WELL: Well Diameter _ _ _ Approximate Depth <br /> Describe Material and Procedure . . . <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 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 a-best•of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO 2WINC <br /> ANDA INAL I19SPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYI:' r DATE <br /> ADDITIONAL. COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIF NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br />