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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0F OFFICE USE: 1631 E. Hazelton Ave . , Stockton, Calif. <br /> Telephone : (209) 466-6781.- <br />'r APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7] <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED- Date Issued <br /> ] (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No,s•, 1862 and the Rules and Regulations of the Sa oaquin Local Health District. <br /> JOB ADDRESS/LOCATIO CENSUS TRACT <br /> Owner's Name Phone <br /> x <br /> Address0 J4 city �- <br />'f Contractor's Name icense #Afola,&Phone �, - <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP. REPLACEMENT <br /> Other l/ / <br /> DISTANCE TO NEAREST: SEPTIC DANK SEWER LINES PIT PRIVY <br /> II` SEWAGE DISPOSAL FIELD CESSPOOL/SEEP- GE PIT OTHER p <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> F INTENDED USE TYPE OF WELL - _ CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of_We11-.Excavation �} <br /> Domestic/private Drilled Dia. of Well -Casing <br /> Domestic/public ! Driven Gauge of Casing,, <br /> Irrigation anon I Gravel Pack ck Depth.-of-Grout Seal <br /> Cathodic Prote on I Rotary Type of Grout <br />` Disposal I Other Other Information (v <br /> Geophysical 1 Surface Seal Installe BY: <br /> PUMP INSTALLATION: Contractor � <br /> 42�� <br /> Type of Pump H. <br /> PUMP REPLACEMENT; Lyl State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DES-TRUCTION OF WELL: Well Diameter . -Csf, Approximate Depth <br /> Describe Material 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 anew well, I will furnish the San Joaquin Local Health District a <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 <br /> PRIOR TO G TING _ DAF NAI;. INSPECTION. -- <br /> SIGNED � TITLE <br /> - y <br /> (DRAW.-PLOT PLAN ON REVERSE' SIDE) <br /> FOR DEPARTMENT USE .ONLY <br /> PHASE I " <br /> APPLICATION ACCEPTED BY liti/ DATE <br /> ADDITIONAL COMMENTS: i <br /> PHASE II GROUT INSPECTION PHASE' II ANAL INSPECTION- <br /> INSPECTION <br /> NSPECTIONINSPECTION BY DATE INSPECTION BY DATE - <br /> F 14 ALTA no.. 1_7.. Y o.71 _ 2M <br />