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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 7� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I. YEAR FROM DATE ISSUED Date issued 11- <br /> • (Complete In Triplicate) <br /> Application is tereby 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. 18 2 a d,it e- Ruly and Reg lattioons of the San o uin Loc Health District. <br /> / o .' �T! - <br /> JOB ADDRESS/LOCATION CENSUS TRACT i <br /> Phone d <br /> Owner's Name <br /> 7�- City O D <br /> Address <br /> 6/ <br /> Contractor's Name License ��Il 7,99/Phone 333y <br /> i <br /> TYPE OF WORK (Check) : NEW WELL +/ ` DEEPEN '/ / RECONDITION /_/ DESTRUCTION /� <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /� k <br /> 0th-er <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 /> t Industrial f/Cab <br /> Ie Tool Dia. of. Well Excavation <br /> Domestic/private �r,__.. . . Drilled „ r.» - . Dia.�of Well Casing <br /> Driven " Gauge of Casing <br /> Gravel Pack <br /> Domestic/public ".Depth of Grout Seal �1 <br /> _�/Irrigation <br /> Cathodic Protection 6"`' ' -Type of Grout <br /> Disposa'1 other:_. . Other Information' : <br /> t " ' '' r t Surface Seal Installed B <br /> Geophysical EX <br /> IPUMP INSTALLATION: Contractor .. H.P. , <br /> TYpe,af Pump _ _ <br /> PUMP REPLACEMENT: /;r1f4 S to-t6,•Work_.D o.J <br /> kPUMP .REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter - -w - _ Approximate Depth <br /> Describe Material and Procedure <br /> ' I hereby agree to comply with ail 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 /> rafter 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 aninot f=y—ttfem"before putt' ng�the.well`"in use"ROThe above" <br /> information is true to the best of my knowledge and belief:; I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO QROUTING AND A FINAL INSPECTION. µ <br /> TITLE <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FORK DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BYT <br /> 'kADDITIONAL COMMENTS: ` . PHASE III/FINAL INSPECTION <br /> PHASE 11 GROUT [INSPECTION DATE , -1� ,P <br /> INSPECTION BY 4DATE INSPECTION BY <br /> .A ! 1177 , 2M <br />