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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. �� �a <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date; Issued <br /> (Complete In Triplicate) <br /> Application is hereby made toIthe 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 ;N61 1862 and the' Rules and Regulations of' the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION, . g. NSUS TRACT <br /> Owner's Name 1- Phone <br /> r <br /> Address — City <br /> Contractor' Name F LicensePhone <br /> i <br /> TYPE OF WORK:(Check)_: WELL- __ DEEP_EN /�/. �,RECONDITTON / _DESTRUCTION. _/�T-, -- _ <br /> PUMP INSTAL ATION / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other ,/ / T� <br /> [ r T <br /> DISTANCE TO NEAREST: SEPTIC TANK -SEWER LINES PIT PRIVY <br /> f ti, SEWAGE DISPOSAL FIELD -CE55POOL/SEEPAGE PIT OTHER <br /> PROPERTY I;INE_ :PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> IndustrialCable Tool-- ` Dia. -of Well -Excavation <br /> Domestic/private 1 ';� Drilled Dia. of=Well Casing fir <br /> y r_ <br /> Domestic/public it Driven Gauge of. Casing x/11 <br /> Irrigation ;•;. Gravel Pack Depth of Grout Seal <br /> Cathodic Protection ;I Rotary Type of Grout r <br /> Disposal "I : Other- "� 1' Other Information <br /> Geophysical - wry. 'Surface Seal Installed B <br /> 09 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 00 <br /> i F <br /> _ �.�.:..+h_.++e.�'rT-......,+....,wr..-w.'.ww..•_:-a.....r•t�...^._�.�..Rso'.. 'vvw_+ - <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 Health District <br /> WELL 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 p <br /> PRIOR.TO GR0U"t1G,,ED,4 FINA I ION• ,. }- � _--� -- - TITLE <br /> SIGNED - - - <br /> SIGNED " <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �J <br /> APPLICATION ACCEPTED BY ! ,gam DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE lI GROUT 'INSPECT N PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY r' DATE I . <br /> k <br /> 9."p 1426 RPu_ 1--74 _ 1 <br />