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� +• SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF-OFFICE USE.: ''y 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby 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 arrd Regulations of the San Joaquin Local Health District. <br />' JOB ADDRESS/LOCATION CENSUS TRACT <br /> r / <br /> Owner s Name� � Phone �--�� <br /> AddressI` �dzi Y`vl city-, <br /> c t License #� U / Phone Name 3 �T3 <br /> A, ti <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN RECONDITION RECONDITION /�/ DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC. TANK -2a 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 /> Domestic/private Drilled Dia, of Well Casing 5< ' <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout ('_ <br /> Disposal Other Other Information <br />!. <br /> Geophysical Surface Seal Installed B <br />� r t <br /> PUMP INSTLLLATION: Contractor S <br /> Type of Pump --------- H.P. <br /> PUMP REPLACEMENT: State Work Done 1" .. <br /> PUMP .REPAIR: / / State Work Done <br /> ; .. <br /> DESTRUCTION OF WELI; 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 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 G OUTING D A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY � �" DATE Q- � <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTIOy BY DAT d <br /> / r)' y Com./Y�LI � � 6 77 _ 2M 74 <br /> F Tj 7/�7 G, U,�,,,� 1—7/, f l �f•"U,.S`! lE/ ✓�I'a`n„ _ 7 r. .� ��J'9i <br />