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SAN JOAQUIN LOCALALTH DISTRICT <br /> F0F OFFICE USE:- � 1601 E. Hazelton Ave. , , Stockton, Calif. 6 <br /> i Telephorm: (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 /> 4 (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 and Regulations of the San Joaquin Local Health District. <br /> r <br /> JOB ADDRESS/LOCATION W e' W A ris CENSUS TRACT " <br /> Owner's Mame r Phone ��5' <br /> �. <br /> 2::,,- <br /> a City' � c0 c <br /> Address o - <br /> f:� Phone <br /> Contractor s Name _ � •- - — <br /> - _. ....- <br /> TYPE OF WORK{Check) : NEW WELL / - DEEPEN / / RECONDITION / / DESTRUCTION / 7 <br /> 4 PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT f_ f <br /> Other !/ / ' <br /> DISTANCE TO NEAREST: SEPTIC TANKS 1d '-f SEWER LINES Lgk:! PIT PRIVY <br />" SEWAGE DISPOSAL FIELD � CESSPOOL/SEEPAGE PIT lap(- OTHER <br /> PROPERTY LINE= PRIVATE DOMESTIC WELL PUBLIC DOMES IC WELL <br /> INTENDED USE TYPE OF WELL a CONSTRUCTION SPECIFICATIONS <br /> i Industrial F ' Cable;Tool Dia. of Well Excavation <br /> Domestic/private "" Drilled Dia. of Well Casing Rr r►� _ <br /> Domestic/public Driven Gauge`ofCasing <br /> Irrigation , Depth- <br /> of Pack Depth of Grout Seal <br /> Cathodic Protection—=�__,k�otary Type of Grout <br /> °Other"' _ ' r Other Information <br /> Disposal --- , a ..� ,,,,,.-. ,art c <br /> Geophysical �' " Surface Seal7'Installed B'` <br /> PUMP INSTALLATION: Contractor" <br /> Type., of Pump! -V $ H.P. F <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> IDES-' RUCTION .OF WELL: Well Diameter Approximate Depth <br /> a <br /> Describe Material -and Procedure <br /> i <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 /> 14ELL 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 /> C PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITL <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY \IWAw" DATE g <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUTIINSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY " .. DATE ; INSPECTION BY DATE <br /> _ A 142E RP-U 1'14 <br />