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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF: OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 r� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. / aT <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �/- 7,2 <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 d J;he Rules Regulatnso he San Joaquin Local Health District. . <br /> JOB ADDRESS/LOC CENSUS TRACT ' <br /> ION <br /> Owner's lame~ e ,-�/ �7�'CJ ---- -- Phone ►' '1� <br /> �4 oar <br /> Address ` r�� ��. _ City <br /> Contractor's Name �� i License # hone q_VVL <br /> a <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN / / RECONDITION /? DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES_ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC 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 CasingI <br /> Domestic/public Driven Gauge of Casing <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 a <br /> Type of 'Pump H.P. <br />' PUMP REPLACEMENT: State Work Done. <br /> PUMP :REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well, Diameter Approximate Depth <br /> Describe-'Material and Procedure <br /> �T <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 the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR TING AND A FINAL INSPECTION. A. ,�z.��, <br /> SIGNED TITLE U "�� 1-� <br /> (DRAW PLOT PLAN ON REVERSE SIDE) _ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE ?—TO-77 <br /> APPLICATION ACCEPTED BY ef, <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY /' DATE <br /> . 1177 ZI <br />