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- <br /> s <br /> C SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF� OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: ' (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2 � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In -Triplicate) <br /> Application is`-hereby -snide to the San Joaquin Local Health District for a permit to construct <br /> and/or install the.work herein described. This appl�ication.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 /> JOB ADDRESS/LOCATION 4)A&WGa.0 •!'i1� 3f4 26 !?kg T ? ( CENSUS TRACT <br /> Owner's Name _ Phone"'�/ <br /> Address 4 ' City '- <br /> contractor's <br /> ity `Contractorss Name �l•C�' License # 'Z"Jaz Phone ' �,Z-6 <br /> TYPE OF WORK (Check): NEW WELL,/ <br /> DEEPEN' '/ RECONDITION /7 DESTRUCTION rf <br /> PUMP INSTALLATION / / PUMP REPAIR'/,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 C <br /> Industrial Cable Tool Dia. of Well Excavation \4 <br /> Aomestic/private : Drilled Dia. of Well Casing ,Z <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation '++ Gravel Pack- Depth of Grout Seal <br /> i Cathodic Protection ! Rotary Type of Grout ' <br /> E' <br /> Disposal' , i Other Other Information <br /> Geophysical- .Surface Seal Installed 'By' <br /> �. PUMP' INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: . / / ,State Work Done <br /> � PUMP .RE PAIR: / / State Work Done 1 ' <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> II hereby agree to comply with all laws and regulations of the Sa'n'--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 <br /> WELL DRILLERS REPORT of the }well and notify them before putting.the..well. in.use.... The above <br /> linform.ation is true to the-best of. my. knowledge and belief. I WILL CALL -FOR A GROUT INSPECTION <br /> PRIOR TO GR UTING'AN FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I D DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION' PHASE III FINAL INSPECTION <br /> INSPECTION BY DATEINSPECTION BY DATE <br /> q <br /> / <br /> r i, 1L7t1 7?nts�'1-7L. _ 4! tmoi <br /> 5 at <br />