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SAN JOAQUIN LOCAL, HEALTH DISTRICT <br /> FOf <br /> 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> OFFICE USE: <br /> � : Telephone: (209) 466-6781 _ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP '-PERMIT Permit No. �1/DdD <br /> '£HSt:PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued.S(/S 77 <br /> (Complete In Triplicate) <br /> Appl 'cation 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 ana lations o he San Joaquin Local Health District <br /> d . <br /> CENSUS TRACT <br /> JOB ADDRESS/L ON v Phone <br /> Owner's Name <br /> f��/ City <br /> Address <br /> License Rff( lhone � <br /> Contractor's Name <br /> ti <br /> TYPE OF WORK (Check} : NEW WELL /-7 DEEPEN / / RECONDITION /�`/ DESTRUCCEMENTTION �j- T <br /> PUMP INSTALLATION / / PUMP REPAIR} PUMP REPLA <br /> Other '/ / <br /> DISTANCE TO NEAREST: SEPTIC .TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD, CESSPOOL/SEEPAGE PIT OTHER <br /> C WELL <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL <br /> PUBLIC gPECIFICATIONS \ <br /> INTENDED USE <br /> TYPE OF WELL o CONSTRU <br /> Industrial Cable Tool Dia: of Well Excavation <br /> p Drilled Dia. of Well Casing <br /> Domestic/private Driven Gauge of Casing <br /> Domestic/public <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br />' <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type 'of Pump <br /> REPLACEMENT: / / State Work Done <br /> i PUMP ti <br /> PUMP .REPAIR ry / State Work Don <br /> Ap roximat6 Depth <br /> ' DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> + L <br /> I hereby 'agree to comply with all laws an11 d regulat 1`0"�i`ls <br /> of the <br /> ecSan Joaquin <br /> o quin.LoWithinaFIh DisiDAYS=� <br /> and the State of California pertaining to or regulating <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <br /> above <br /> WELL DRILLERS REPORT of the well and notify them before putt I WILL CALL FOR AeGROUTe <br /> b INSPECTION <br /> information is trug the well in <br /> e to the best of my knowledge and <br /> PRIOR TO GROUT NG AND A FINAL INSPECTION. TITLE <br /> SIGNED <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY ,t►� <br /> PHASE I DATE- lam_ <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHAS IfII INAL INSPEC'TI <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE Z <br /> INSPECTION BY 1, rDATE <br /> 2 <br /> r v IL14 Dom„ 1-7G -- - - <br />