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----�_ SAN JOAQUIN LOCAL. HEALTH DISTRICT ' <br /> FOR 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 /> (Complete In Triplicate) <br /> Application is Aereby 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 th Rules and Regulations f the San oaqu n Local Health District. <br /> JOB ADDRESS/LOCATION I <br /> CENSUS TRACT <br /> Owner's Name 1 <br /> al __41 <br /> Phone <br /> �r <br /> Address <br /> city <br /> Contractor's Name <br /> License Phone <br /> TYPE OF WORKCheck) ; <br /> ( NEW WELL/ DEEPEN _ <br /> / / RECONDITION /—/ DESTRUCTION /7 � <br /> PUMP INSTALLATION 0 PUMP REPAIR / / PUMP REPLACEMENT /_7 g� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 6� <br /> SEWAGE DISPOSAL FIELD CESSPOOL;/SEEPAGE PIT _ OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL ^ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> .Domestic <br /> /private Drilled Dia, of Well Casing 'Or (, <br /> Domestic/public Driven Gauge of Casing , <br /> Irrigation Gravel Pack - Depth of Grout Seal <br /> Cathodic Protection Rotor <br /> Disposal' Other Type of Grout <br /> Other Information <br /> Geophysical � Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> ' H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP '.REPAIR: / / State Work Done <br /> _— p <br />)ESjRUCTION 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 /> ind the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> ifter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> JELL DRILLERS REPORT, of the well and notify them before putting the well in use. The above <br /> Lnformation is true t e best of. my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION r <br />'RIOR TO GROUTIN- 1_.INAl-t-4-NS°P°E-6 IO <br />'IGNED <br /> TITLE <br /> af(DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEP MP. o .7re,E .ONLY <br />'RASE I <br />►PPLICATION ACCEPTED BY DATE /3 g , <br /> JDDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECT ON - PHASI I/ I ECTION <br /> INSPECTION BY � � DATE 'Z 7 INSP, : <br /> ECTION E <br /> E H 1426 Rev_ 1-.7A l IAy f.:n. A-0 +,04� .,L0, 1 177 ..;, <br />