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E ' <br /> FO OFFICE USE: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ------- 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) ,466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> ZZZW <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> J Date Issued <br /> (Complete In Triplicate) <br /> Application i reby made to 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 () <br /> CENSUS TRACT <br /> Owner's Name S <br /> Phone <br /> Address <br /> City <br /> Contractor's Namet-• �� <br /> License #a� Phone & <br /> TYPE OF WORK (Check) : NEW WELL DEEPENT- -~�✓�_-�-_ -��}- -- '��-_. _ .. <br /> RECONDITION /? DESTRUCTION � <br /> PUMP INSTALLATION R PUMP REPAIR / / PUMP R <br /> Other EPLACEMENT? <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> PROPERTY LTNE -- PRIVATE DOMESTIC WELL - PUBLIC DOMESTI�TWELI <br /> INTENDED USE TYPE OF WELL <br /> Industrial - � -- ___CONSTI3UC0�1 SPECIFICATIONS ® . <br /> Cable Tool Dia, of Well Excavation IM <br /> Domestic/private Drilled Dia, of Well Casing — <br /> Domestic/public Driven G '-Gauge,-of Casing <br /> Irrigation - - <br /> Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal 4a .3 `*.ti ;� �: Other -j Other Information <br /> Geophysical _ �- <br /> z sf Surface Seal Installed By: <br /> PUMP INSTALI•ATZON: , .,. i„X Contractor- D <br /> ' <br /> Type of Pump- <br /> H.P. <br /> um <br /> pT; t <br /> H,p, <br /> PUMP REPLACEMENT: / State,�,Work Done t' <br /> PUMP .REPAIR: / / State Work Done <br />)ES•TRUCTION OF WELL: Well Diameter y <br /> Describe Material and Procedure Approximate Depth <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 />+SELL 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 /> RIOR TO GROU G AND A N INSPECTION. <br /> i IGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID ) <br />,HASE I FOR DEPARTMENT USE ONLY <br /> LPPLICATION ACCEPTED BY <br /> JDDITIONAL COMMENTS: DATE _ 11-1-1—_22 <br /> PHASE II GROUT INSPECTION PHASE TT /FIN INSFECTION <br /> NSPECTION BY DATE INSPECTION BY <br /> DATE /2 �r <br /> E H 1426 1_7.. C� <br />