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r � �ft 4 Lr'jo 4 W IJ �z.`Z •. <br /> g»,rr SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> f., Telephone: (209) 466-6781 �k <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT ; Permo. (7 <br /> f 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 b q K CENSUS TRACT <br /> Owner's Name / " l 11, K A Phone S <br /> Address S �6 �/6.6 City <br /> Contractor's Name / License j / 'honeG <br /> i <br /> TYPE OF WORK (Check) : NEW WELLA, DEEP&,/ / RECONDITION / / DESTRUCTION fwT <br /> PUMP INSTA:LLATIOUMP REPAIR / / PUMP REPLACEMENT /� <br /> �. Other ,. <br /> DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES ? PIT PRIVY - P p <br /> SEWAGE .DISPOSAL FIELD CESSPOOL/SEEPAGE PTT OTHER <br /> §. PROPERTY.,LINE• - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Gable. Tool Dia. of.- Well Excavation <br /> Domes°tic/private AF� Drilled Dia. of,:Well Casing <br /> Domestic/public. ­.'.Driven, Gauge of Casing <br /> Irrigation f "bravel'Pa�ck Depth of Gf©ut Seal <br /> Cathod-i.c Protection Rotary Type OfGrout <br /> Disposal' Other„ .,F. Other Information <br /> p Geophysical , Surface Seal Installed By: <br /> PUMP INSTALLATIOfl� Contracto •� <br /> > `Type of Pump , .. '' H.P. <br /> r <br /> -PUMP REPLACEMENT: / / `State Work Done r" 5. <br /> 4 '_ <br /> PUMP .REPAIR: > / /.__ State Work Done k� <br /> DES•TRUCTION,OF WELL: Well Diameter ` Y Approximate Depth e :y <br /> ' - Describe Material and Procedure . <br /> d i <br /> I hereby, agree to comply with all laws and regulations'�6f*-the San Joaquin Local Health District <br /> and the-State of California pertaining regulating well •construction. Within FIFTEEN DAYS <br /> ' after completion of my work on a new well, I will furnish the San Joaquin:.Loca1 Health District a <br /> WELL DRILLERS REPORT of `the -well and notify them'�before putting the,-...well MIn use_, The above <br /> information ;is true to the best of my knowledge-and belief. . "IIWILL CALL-FOR-'A GROUT INSPECTION <br /> PRIOR TO GRO I D A .NAL INSPECTION: <br /> SIGNED �,. ., -TITLE <br /> DRAW:M T" PLAN ON RE FRSE SIPE) 4 <br /> r FOR DEPARTMENT USE ONLY - <br /> PHASE <br /> APPLICATION ACCEPTED BY 'Y? DATE' <br /> F ADDITIONAL COMMENTS: <br /> { PHASE II GROUT INSPECTION <br /> � . PHASE II /FIN INSPECT N , <br /> INSPECTION BY DATE INSPECTION'BY DATE ' <br /> ;� <br /> E"H 142.6.. Rev. =;74. <br />