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SAN JOAQUIN LOCAL HEALTH DISTRICT q <br /> FOF OFFICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> I,. Telephone:. (209) 466--6781 . -17/�e <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> a <br /> THIS. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED T, Date Issued f <br /> (Complete In Triplicate) R <br /> Application is hereby made to�lthe San Joaquin Local Health District for a permit to construct <br /> is made in compliance with ,San Js <br /> and/or install the work hereifi described. This application ct. <br /> County Ordinance No- ,1862 andithe Rules and Regulations of the .San .Joaquin Local Health District. <br /> a <br /> APP <br /> CENSUS ,TRACT <br /> JOB ADDRESS/LOCATIO.N ?. <br /> y <br /> Owner's Name t t <br /> Phone <br /> 11 City <br /> AddressJOS 6, <br /> Contractor's Name C.e.lG ' Cr. License # ,�-f'hone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION / / DESTRUCTION — <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 DOMES`T'IC WELL, PUBLIC DOMESTIC WELL <br /> ON SPECIFICATIONS <br /> CONSTRUCTION INTENDED/USE TYPE 4F WELL <br /> Industry'a1 --i-Cable Tool Dia. of Well Excavation <br /> Domestic/private FI Drilled Dia. of Well Casing <br /> Domestic/public i17:_ Driven Gauge of Casing <br /> Irrigation ion <br /> J Gravel Pack Depth of Grout Seal <br /> g - <br /> Type of Grout <br /> Cathodic Protection f. Rotary <br /> Disposal ;I Other Other Information <br /> Geophysical Surface Seal Installed B <br /> 1� <br /> PUMP INSTALLATION: Contractor <br /> Type hof Pump - <br /> _ �f <br /> PUMP REPLACEMENT: / / ;State Work Done <br /> r <br /> PUMP REPAIR: {State Work Done <br /> ®" <br /> VV <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 of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO TING AND A FINAL INSPECTION. <br /> TITLE <br /> SIGNED . -� <br /> RAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPAR NT USE ONLY <br /> or <br /> . PHASE I DATE <br /> _4 APPLICATION ACCEPTED BY <br /> 1 ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHS .., III/' A INSPECT It <br /> DATE INSPECTION B` <br /> INSPECTION BY <br /> E I7 _ 2M <br />