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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> -To-r--,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 5 <br /> Telephone : (209) 466-6781 <br /> k APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit -No. Zf D) � <br /> THIS PERMIT -EXPIRES 1 YEAR FROM -DATE ISSUED Date Issued ,�-W// <br /> (Complete In Triplicate) <br /> i Application is hereby made to the San Joaquin L alth District for a permit to construct <br />{ and/or install the work herein described. is appl�ica" is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of he San Joaquin Local Health District. <br /> f t <br /> JOB ADDRESS/LOCATION e Cs ENSUS TRACT <br /> Owner's Name —AD Phone <br /> Address City /1�2 <br /> Contractor's Name 7lJ License # a &/() Phone <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 DOMESTIC WELL PUBLIC DOMESTIC WELL, <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia; of Well Excavation <br /> Domesti0private Drilled Dia, of Well Casing <br /> Domestic/public, . ` Driven Gauge of Casing <br /> Irrigation'; Gravel Pack Depth of Grout" Sea1 <br /> Cathodic' Protection Rotary Type e of Grout . <br /> Disposal y .', Other Other Information <br /> Geophysical _ _ <br /> Surface Seal Installed By:. . . ,...,..__ <br /> PUMP INSTALLATION: Contractor .y <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done ] en tqzl &Izh <br /> PUMP -REPAIR: / J State Work Done <br />' DES-TRUCTION OF WELL: Well Diameter Approximate Depth <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 we11 '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 i rue to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROPTITIG AND A FINAI, INSPECTION. <br /> SIGNED hz>i , <br /> TITLE �� J <br /> ii.{ " .r` L {DRAW PLOT PLAN ON REVERSE SID T <br /> r ' FOR DEPARTMENT USE ONLYPHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS,.- <br /> PHASE 1j, <br /> OMMENTSPHASE `1 , OUT--INSPECTION PHASE I TNAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE <br />