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SAN JOA:QUIN LOCAL HEALTH DISTRICT' <br />{ FOR.OFFICE USE: ( }.601 E. Hazelton Ave ' $ Stockton, Calif. <br /> � . Telephone: (209) 466-6781 <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 hereby made: to the Son-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 , CENSUS TRACT <br /> Ownei's Name Phone , <br /> J - <br /> Address �/ .3 .�" J(f ,� City 7 <br /> Contractor's Name �' }�, License # (l2 Phone57.9 <br /> TYPE OF WORK (Check): NEW WELL DEEPEN/7 RECONDITION f7 DESTRUCTION' fN <br /> PUMP INSTALLATION/ / PUMP REPAIR-/-7 PUMP REPLACEMENT <br /> Other / <br /> DISTANCE TO NEAREST: . SEPTIC TANK J SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSSF'IELD ' CESSPOOL/SEEPAGE PIT OTHER . <br /> PROPERTY LINES-t PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> r Industrial # Cable Tool Dia. of Well Excavation _ /0 `U <br />�i Domestic/private a Drilled Dia. of We11-Casing- G <br /> Domestic/public .1 Driven Gauge of Casing <br /> Irrigation- ` E Gravel Pack: Depth of Grout Seat , <br /> Cathodic Protection Rotary Type ,of Grout <br /> Disposal t Other Other"In€ormation <br /> Geophysical i Surface`�Seal Installed 'B i <br /> PUMP INSTALLATION: Contractor <br /> ` Type .of.Pump <br /> W :, s - <br /> PUNP REPLACEMENT': 7-:' / /�State Work Done <br /> PUMP ,REPAIR: <br /> /� :state�Work bone <br /> DESTRUCTION OF WELL: Well Diameter - t Approximate Depth tab <br /> __Describe .Materal and Procedure „ <br /> I hereby agree to 'comply with all lawstand regulations of the-San 'Joaquin 'Local Health District <br /> and the Sta;e;of California' pertaining'to or regulating."well_cons.truction. 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 GROUTING AND A nNAL INSPECTION. <br /> SIGNED 3 . TITLE a <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> 1 <br /> FOR DEPARTMENT USE ONLY i <br /> PHASE I , <br /> APPLICATIO <br /> N--ACCEPTED , , , .-.DAT$-- - - i <br /> _. -. . C J YY e C <br /> ADDITIONAL COMMENTS.. 01 <br /> PHASE II GROUT I SP ION ''-•' PHASE 1141FINAL INSPECTION <br /> INSPECTION BY DATE &P •o& INSPECTION BY. DATE <br /> c_ <br /> E H 1426 r <br /> Ren. 1-74 _ _h/75_ 2M_ <br />