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' SAN JOAQUIN LOCAL HEALTH DISTRICT / P <br /> FOF.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. v <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Per <br /> No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> pplication 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 /> �ounty Ordinance No. 1 6� the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION /�#)Wg) OF RiLw Rj S`XjaA/ CENSUS TRACT <br /> Ver's Name �"F}Kc �/ SAI 8 P r k u M Phone 5-9'9 -3s`/0 <br /> dress (00 be. � city Q/Poll <br /> ontractor's Name /)(-$ 1,&Lef e_ License # 3 .595 Phone <br /> YPE OF WORK (Check) : NEW WELL/—/ DEEPEN '/ / RECONDITION / / DESTRUCTION /_T <br /> AL <br /> PUMP INSTLATION '/ / PUMP REPAIR/ / PUMP REPLACEMENT /-T <br /> Other X &A& Af&/ f 4/ <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 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven ,Gauge of Casing <br /> Irrigation Gravel Pack ( Depth of Grout Seal <br /> Cathodic Protection Rotary �; Type of Grout <br /> Disposal Other r Other Information" <br /> Geophysical "Surface Seal Installed Bv: <br /> i <br /> ,PUMP INSTALLATION: Contractor /V H.P. <br /> Type of Pump T^cLV s u 2 - <br /> � ,- <br /> 'PUMP REPLACEMENT: / / -State Work Done <br /> �-� LSC Ga lam ►�. <br /> PUMP •.REPAIR: /y/ State Work Done � <br /> ,DESTRUCTION 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 /> 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 of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO I/NNGAND� A FINAL INSPECTION. / <br /> ' <br /> SIGNED TITLE <br /> T - DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY p <br /> PHASE I DATE .--2 X f7 <br /> ' APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA E I FIN INSPECTI N <br /> DATE INSPECTION BY DATE 0' <br /> INSPECTION BY too <br />