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m SAN JOAQUIN LOCAL HEALTH DISTRICT ?69 36a <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. - <br /> Telephone ; (209) 466-6781 1 i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 71�/l� <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued �1 <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 Joequin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San, Joaquin Local Health District. {�{ <br /> i <br /> JOB ADDRESS/LOCATION Q ! CENSUS TRACT <br /> i' <br /> Owner's Name G�inC Phone <br /> r <br /> Address City r <br /> Contractor's Name License Phone3�� j <br /> TYPE OF WORK (Check) : NEW WELL-/_/ DEEPEN /_/ RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION REPAIR / / PUMP REPLACEMENT /-7 g <br /> -Other / / r" <br /> DISTANCE TO NEAREST: SEPTIC TAN SEWER LINES/!(IX,e PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEWGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELI, ? PUBLIC DOMESTIC WELL SL <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 Other Information <br /> Geophysical Surface Seal Installed By: <br /> 3 <br /> PUMP INSTALLATION: Contractor . <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP ,.REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Dept� <br /> Describe Mater'a1 and Procedure tp 6 � ce <br /> I hereby agree to comply with a1 ' laws and regu-1aitions of the San Joaqu n 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 GROUTING A NAL INSPECTION. <br /> SIGNED , T.ITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) j <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 9 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASEI I/F NAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY - DATE 22 <br /> w u IAIK : 1777 W <br />