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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. • 7? -/-S <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 and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION JY Cpp � ; CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Ef <br /> Address City <br /> Cont a. p, <br /> Contractor's Name "� -- _ License _��(j-��-Ph O..:j 24 <br /> TYPE OF. WORK (Check) : NEW WELL DEEPEN / / RECONDITION / / DESTRUCTION /� <br /> PUMP INSTALLATION A< PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / } <br /> DISTANCE TO NEAREST: SEPTIC TANK 10,of SEWER LINES /0,0 7 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD/SV/ CESSPOOL/SEEPAGE PIT _ OTHER <br /> PROPERTY LINE — PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELT, <br /> �^ INTENDED USE -.a TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial `'� , Cable Tool Dia, of Well Excavation /a <br /> 5L Domestic/private Drilled Dia. of Well Casing � 6 <br /> Domestic/public Driven Gauge of Casing Z <br /> Irrigation` Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Rotary Type of Grout <br /> E Dispos.a] �. F' ¢ ?};,Other Other Information <br /> Geophysical'—' , t .a.- =. Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor- <br /> .Type of Pump 01H.R. / <br /> PUMP REPLACEMENT: V <br /> State Work Done <br /> PUMP REPAIR: <br /> / / State Work Done . <br />` DES-TRUCTION OF WELL: Well Diameter <br /> Approximate Depth. _ , I <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 9kealth 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 th�bbestof- owledge and belief. I WILL CALL FOR A GROUT INSPECTIONPRIOR TO GROUTI A F . <br /> SIGNED TITLE C <br /> DRAW PLOT PLAN ON REVERSE SIDE) � <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY -DATE INSPECTION BY DATE <br /> .E__H I426_' _Rev. 6177 _ 2M <br />