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•- -. d a <br /> . SAN JOAQUIN LOCAL HEALTH DISTRICT <br />�. FOR: OF I USE: <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-678.1 GS <br /> APPLICATION FOR WELL CONSTRUCTION OR .PUMP PERMIT Permit No. 17,f 1d <br /> THIS PERMIT EXPIRES 1,. YEAR- FROM DATE ISSUED7 <br /> Date Issued3_ <br /> (Complete In.Triplicate) <br /> Application is is hereby made to the San Joaquin Local Health District for a permit <br /> t <br /> and/or install the work Herein <br /> County Ordinancedescribed. This application is made in compliancewithnSanuJoa uin ' <br /> .No. .1862 and the Rules, Regulations of the :San Joaquin Local -Health District. <br /> q <br /> i <br /> JOB ADDRESS/LOCATION- <br /> CENSUS TRACT <br /> Owner's Name , <br /> r Phone <br /> Address <br /> �. <br /> • � !� '►'{ city <br /> Contractor's Name �! <br /> License # hone <br /> Z-� <br /> TYPE OF WORK (Check) : NEW WELLi <br /> / DEEPEN RECONDITION ,/ DESTRUCTION /� <br /> PUMP INSTALLATION IX71 PUMP REPAIR �/ PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIY_ OTHER <br /> INTENDED USE <br /> PROPERTYILINE ; PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL- <br /> Industrial TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavation X <br /> Domestic/private Drilled <br /> Domestic Dia, of Well Casing <br /> /Public ;1 Driven Gauge of Casing <br /> Irrigation r1 Gravel Pack <br /> Cathodic Protection f yof <br /> Pe Grout <br /> f Rotary Tp oGrout Seal F <br /> Disposal <br /> {1 Other , Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION- <br /> ' <br /> Coritractot x <br /> } Type of�EPuMP <br /> H.P. <br />'UMP REPLACEMENT• / / S t I�te Work D . <br /> one <br />'UMP R: r/ State. 4/Done <br /> ES_ TRUCTION OF WELL: Well Diameter <br /> Describe .Material and Procedure Approximate Depth <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> nd the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> fter completion of my"work on `a new well, I will furnish the San Joaquin Local Health District a <br /> ELL DRILLERS REPORT of the well and notify them before puttzng. the well in use.. The above <br /> nformaZIOR <br /> T tion JT true to the best of- mq k wl <br /> 3IOR e nd belief. WILL WILL CALL FOR A GROUT ••INSPECTION <br /> TO G [TYING AND A FINAL INSP C IO <br /> IGNED • - <br /> TITLE <br /> RAW PL T LAN ON VERSE SIDE) <br /> 1ASE I FOR DEPARTMENT -USE ONLY <br /> PPLICATION ACCEPTED BY <br />)DITIONAL <br /> COMMENTS: J DATE <br /> JSPECTION BY <br /> PHASE II GOUT INSPECTION PHASE III FINAL INSPECTION <br /> DATE INSPECTION BY <br /> K DATE , `? <br /> E H 1426' Rev. - I-74 b;]7 o ,r <br />