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• F <br /> SA OAUU114 LUCHL h6ALTH DISTRICT <br /> FOE OFA CE VS 1601 E. Hazelton Ave. , Stockton, Calif. . <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No..� 3• <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /o /6_�g <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 />;ounty Ordinance No. 1862 and the Rules and ta u1to s f the San.Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS 'TRACT t <br /> 3wner's Name Phone <br /> Address City <br /> 572-/-3/ <br /> lontractor's Name mo i- License U 'Phone <br /> J <br /> TYPE OF WORK (Check): NEW WELL / "/' DEEPEN '/ / ZECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other /' / <br /> C <br /> ISTANCE 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 l(, <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICff&ONS <br /> �csdustrial Cable Tool Dia. of Well Excavation � <br /> —fy Domestic/private �T'Drilled Dia. of Well Casing . <br /> Domestic/public Driven Gauge of- Casing <br /> Irrigation _,, 6ravel Pack Depth of Grout.Seal <br /> Cathodic Protection r Rotary Type of Grout �/ ✓r " % <br /> Disposal Other Other Information � 4 <br /> Geophysical Surface Seal Installed Bv- <br /> SUMP INSTALLATION: Contractor <br /> Type of Pump` H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> IPUMP .REPAIR: / / State Work Done <br /> IESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Progdure <br /> I hereby agree to comply with .kll laws"and regulatious of the San Joaquin Local liealth- 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 .s l in e. The above <br /> information is true to the best of.my . wledge and belief. I WIL L FOEsROUT TNSPECTION <br />'RIOR TOGRO ING AND A FIN S GTI <br />•SIGNED TITLE f <br /> DRAW P ' T LAN ON REVERSE SIDE) <br /> FOR DtPARTIIENT"USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED.BY I,� =�C EaT � .'`�', - DATE <br /> ADDITIONAL COMMENTS: <br /> PHAS I ROUT INSPECTI N PHASE III/FINAL INSPECTION <br /> INSPECTION BYDATE '4 INSPECTION BY DATE <br />