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- SAN JOAQUIN LOC91-HE44 TH DISTRICT <br /> FOR OFFICE USE: ✓ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THz'S PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued / 3-7 <br /> (Complete In Triplicate) <br /> Application is hereby made td: 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 and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION N _ CENSUS TRACT <br /> Owner's Name ryz4zlv 0 Z Z Phone !2 <br /> Address 0.? C2 ., 1V.,, _ f-A za:1A-6/ City s�acf'ta 9 f <br /> .0 <br /> Contractor.'s Name /�� /ir /Vc License ���.�( ..Phone <br /> (AS y <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN '/ J RECONDITION/Z/_ DESTRUCTION /� \ <br /> PUMP INSTAlATION / / PUMP REPAIR / / PUMP}REPLACEMENT /? V <br /> Other <br /> k ' <br /> DISTANCE TO NEAREST: - SEPTIC TANK SEWER LINES2 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD — CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE/6 iRIVATE DOMESTIC WELL_ PUBLIC DOMESTIC WELL <br /> INTENDED USE TTYPE OF WELL CONSTRUCTION SPECIFICATIONS, <br /> Industrial. Cable Tool Dia.. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> XIrrigation i Gravel Pack Depth of Grout Seal. <br /> Cathodic Protection t Rotary Type of Grout ' --- <br /> Disposal i Other Other Information <br /> Geophysical. � Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / /: - State Work Done <br /> f PUMP :,REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br />� 1 hereby agree to comply with]all laws and regulations of .the_ San Joaquin Local Health District <br /> Eand 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 we11 and notify them before putting the -well in use. The above <br /> information is true to the es of y nowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />'`PRIOR TO G ANVA F AL SP ON. <br /> SIGNED TITLE & E <br /> (DRAW PLOT PLAN ON REVERSE SIDE) i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY / /Q DATE <br /> ADDITIONAL COMMENTS: 1 <br /> _PHASE II GROUT INSPECTION Psj_illjFINAL INSPECTION <br /> INSPECTION-.By - ...--INSPECTION BY- DATE <br /> f <br /> 11z7 . 2M <br /> F' N 7l�?h 'Ro,y 1-71, - -- _� <br />