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_ Aa 0 eff SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO&:0 BICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: .(209) 466-6781 <br /> '- APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3= �8'� <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 V.7. . " /. & CENSUS TRACT L C.6- 0 20 <br /> Owner's Name A AA Phone <br /> Address ! % City . <br /> Contractor's Name License # 3 i Phone g�-76 2 6 <br /> a <br /> TYPE OF WORK (Check) : NEW WELL I-T DEEPEN /'/ RECONDITION /_7 / O <br /> PUMP INSTALLATION / PUMP REPAIR J-]—pump REPLACEMENT17 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SSR LINES PIT PRIVY j <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL. PUBLIC DOMESTIC WELL <br /> s INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven y Gauge of Casing } <br /> Irrigation Gravel Pack' Depth of Grout Seal <br /> r <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ' ' <br /> Geophysical Surface Seal. Installed B <br /> PUMP INSTALLATIONo Contractor <br /> Typeof Pump <br /> . yyya <br /> PUMP REPLACEMENT: . /_7 State Work Done - <br /> PUMP .REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> ., <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 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. - my wledge d belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR UTING AND FINAL TAPENrI .J . <br /> SIGNED <br /> z W PLOT PLAN ON NUERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ' 7iS� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FUJAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE P+ Z-f <br /> E ii 1426 Rev. .1-74 { "� <br /> ,x/75 2M <br />