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" Q `SAN JOAQUIN LOCAL HEALTH DISTRICT . <br /> FOF OFFI E USE: � _ 1601 E. Hazelton''Ave: , Stockton, Calif. <br /> Telephone ; (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM. DATE ISSUED Date Issue y-� <br /> e '(Complete In Triplicate) , <br /> Application is hereby made toll the San Joaquin Local Health District fora 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 andithe .Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �� wn di.S. Ay CENSUS TRACT <br /> - _ <br /> Owner's Name, C Phone- <br /> City <br /> Address <br /> -'T'hone <br /> Contractor's Name <br /> License �� �_ � <br /> ,TYPE OF WORK (Check) : NEW WELL DEEPEN /�/ RECONDITION /_/ DESTRUCTION /^J <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT ILcI <br /> Other,1/ f <br /> DISTANCE TO NEAREST: SEPTIC:TANK SEWER LINES : PIT PRIVY <br /> SEWAGEDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial :t Cable Tool Dia. of Well Excavation Hr � <br /> Domestic/private Drilled" Dia. of -Well Casing \ ^ <br /> Domestic/public i Driven Gauge of Casing �? <br /> Irrigation 1 Gravel Pack Depth of Grout Seal <br /> Cathodic Protection i Rotary Type of Grout <br /> Disposal q . '° i Other Other Information <br /> Geophysical ""'� -�„r _ Surface Seal Installed By . <br /> iJ; <br /> PUMP INSTALLATION: Contractor �• <br /> Type ;of Pump r H.P. <br /> i �— .. . <br /> PUMP REPLACEMENT: / IState Work Donees df� <br /> PUMP .REPAIR: / / 'State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well+'Diameter pp <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 the best o knowled e-and lief. I WILL CALL FOR A GROUT INSPECTION <br /> .. PRIOR TO GROUTING ING AND A FINAL SP <br /> SIGNEDfiLE __ ✓' N - <br /> RA OT PL ON REV SE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> C PHASE I DATE 'I <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III./FINAL INSPECTION <br /> PHASE II GROUT I INSPECTION DATE <br /> INSPECTION BY !DATE INSPECTION BY <br /> 2M <br /> 1-74 -_ <br />