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"f SAN JOAQUIN LOCAL HEALTH DISTRICT- <br /> FOF OFFICE USE; . 1601 E. Hazelton Ave. , Stockton, Calif. 4 CAN ED 1 <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 /> 4 (C6mplete 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. 1.862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION /jf CENSUS TRACT <br /> i <br /> ti <br /> Owner's Name 4 ` Phone o _ / F <br /> tl <br /> AddressX077� <br /> City . - <br /> Contractor's, Name License73_Ph one3� <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION 0< PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other <br /> 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK /'op I SEWER LINES /00 PIT PRIVY a <br /> SEWAGE DISPOSAL FIELD/yam r CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL - o- <br /> INTENDED USE _. TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation /6 el <br /> yL <br /> Dome stic/private, Drilled Dia, of Well Casing (� el <br /> Domestic/pub`lic Driven Gauge of Casing <br /> Irrigation` Gravel Pack Depth of Grout Seal <br /> Cathodic ProtectionRotary Type of Grout <br /> Disposal F Other Other Information <br /> Geophysical ' �� r, # Surface Seal Installed B <br /> a. i. <br /> PUMP INSTALLATION: Contractor • � i <br /> Type of Pump : H,P, # <br /> PUMP REPLACEMENT; / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: 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 keaith District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use.. The above <br /> information is t e to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTI A FIUA INSPEC ION. <br /> SIGNEDTITLE i <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY24�J_ <br /> DATEc <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY ,A DATE -7 INSPECTION BY DATE <br /> _ E H--142d^� __Rev.�1=7*-._ - --�* .�-�--.� 0,x%7 2M � . <br />