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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FO> OFFICE USE: 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 /> F <br /> (Complete In Triplicate) <br /> Application is hereby made tothe 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 CENSUS TRACT <br /> ' A 3r— <br /> Phone . ill <br /> Owner's Name <br /> Address City <br /> Contractor's Name License ��: Phane <br /> a <br /> TYPE OF WORK (Check) :. NEW WELL/ I DEEPEN -/ / RECONDITION / / DESTRUCTION /f <br /> PUMP INSTALLATION /^/ PUMP REPAIR / / PUMP REPLACEMENT Lam, <br /> Other <br /> I j <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 . , N, CONSTRUCTTON .SPECIFICATTONS <br /> Industrial x Cable Tool ". .Dia. of- Well Excavation <br /> Domestic/private ' Dia. of Well. Casing v <br /> °Drill <br /> '1 ed Gauge of Casing <br /> Domestic/public !P Driver► g <br /> Irrigation Gravel Packt Depth of Grout Seal <br /> Cathodic Protection IF Rotary Type of Grout <br /> Disposal Other i Other Information <br /> Geophysical * Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> f PUMP REPLACEMENT: 1`f tate Work Done <br /> : oI <br /> PUMP .REPAIR: / / State Work Done <br /> k Approximate Depth <br /> DESTRUCTION °OF WELL: Well±Diameter <br /> Describe Material and .Procedure <br /> F <br /> fI 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 completionof my work :on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of thetwell and them before putting the.-well in use. <br /> The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO UT G AND A F NAL IN ECTZON. <br /> SIGNED <br /> TITLE _ ✓ <br /> (D W PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE IDATE 3 r <br /> APPLICATION ACCEPTED BY 610 <br /> ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> PHASE If <br /> GItOUTI INSPECTION INSPECTION BY DATE <br /> ' INSPECTION BY ►DATE <br /> ' <br /> .1177 ._ 2M <br />