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SAN JOAQUIN LOCAL HEALTH DISTRICT r+./ <br /> FOR.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. Cf/ <br /> F Telephone: (209) 466-67$1 7„ <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 h+eieby 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 Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local. Health District. <br /> k JOB <br /> ADDRESS/LOCATIONy'� � CENSUS TRACT <br /> Owner's Name _ 2.g*- _ _,_......_,._.._ Phone , <br /> Address r 'r �� City S �� .- <br /> Contractor's Name LicenseQ3;7-,-Phone <br /> TYPE OF WORK (Check) : NEW., LL DEEPEN '/% RECONDITIONS./-7 DESTRUCTI/�- <br /> PUMPJINSTALLATION 0 PUMP REPAIR / `/ PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT,2=! OTHER <br /> PROPERTY LINEAd4RIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing G' � <br /> i Domestic/public Driven' Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout _ <br /> Disposal pther'R"""^"` "' Gtll—e Informat ffoff--r <br /> Geophysical , Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. .2— <br /> _ r <br /> PUME' REPLACEMENT: / / State�W0T Dome"'`---" <br /> PUMP .REPAIR: / / ^ State;Work Done .; <br /> DESTRUCTION OF WELL: Well Diameter ; "'' <br /> � Approximate Depth <br /> Describe Material and Procedure ,, .. <br /> E I ,hereby agree to comply with all ,laws and regulations of the San Joaquin Local Health District <br /> and the State. of Californialpertaining to or regulating well 'mconstruction.: Within FIFTEEN DAIS <br /> k after completion ,of my work' on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT +well and notify them before putting the well in use`. .` The�,above <br /> information. is tru to the,best o my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO I ECTION. <br /> SIGNED TITLE <br /> " } (DRAW PLOT PLAN ON REVERSE SIDE} <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I --,.�. -11 <br /> APPLICATION ACCEPTED BY 4 DATE -I 7 '7,7 <br /> ` ADDITIONAL COMMENTS• <br /> P UTiINSPECTION " . PHASE III/FINAL INSPECTION <br /> INSPECTION BY ,J I DATE /-� =�J� INSPECTION BY r DATE - ,3/ -.7 <br /> Rev. f-74 E H 1426 _ �- 1177. .. 2K <br />