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v t SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOk OFFICE USE: �� 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466-6781 7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No./ f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued LL* <br /> 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 Joaqui <br /> ,ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �Q� « p tt a (' �X CENSUS TRACT <br /> 4,r,-t, - <br /> V <br /> _timer's Name _(?_ �, i Ma -fir 7,- Phone / / <br /> 4ddress O. 13 O 7G S d City S�pC, 4e <br /> contractor's Name (S4:edL)r. / r .. . �� License # de 7" Phone ClGk _x7 j <br /> 'TYPE OF WORK (Check): NEW WELL / / DEEPEN/ / RECONDITION /7 DESTRUCTION /-7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR /X/ PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <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 o: <br /> Domestic/private Drilled Dia. of Well Casing a <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal o <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> !l '� <br /> .UMP INSTALLATION: Contractor � t ,, <br /> Type of Pump H.P. <br /> 'UMP REPLACEMENT: <br /> / / State Work Done <br /> PUMP '.REPAIR: , <br /> State Work Done p df 4, t4Q <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> C 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 /> 4ELL 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 kno , dg land belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO U ING AND A FINAL INSPECTI <br /> SIGNED <br /> E n� <br /> (DRAW EL91 PLAN ON REVE E SIDE) <br /> FOX DEPARTMENT USE ONLY <br /> ?RASE I ,- <br /> `�PPLICATION ACCEPTE Y <br /> Z, X DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS ,�III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B. DATE <br /> t <br />