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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOK;,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. z7- tomp <br /> 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 Q CENSUS TRACT <br /> Owner's Name � � _w Phone <br /> - .►--- ? <br /> Address City . <br /> Contractor's Namer v s p cense /Phone <br /> TYPE OF WORK (Check) : NEW WELL/7 DEEPEN /7 RECONDITION / DESTRUCTION /-]• <br /> PUMP INSTALLATION /_/ PUMP- REPAIR '/ 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 Vl <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> D c/public Driven Gauge of Casing q <br /> Irrigation. Gra Pack Depth of Grout Seal <br /> Cathodic Protection otary Type of Grout <br /> Disposal. Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type Of.'Pump B.P. <br /> i <br /> PUMP REPLACEMENT: / / State Work Done i <br /> PUMP? .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of Calif is pertaining to or regulating well'�construction. Within FIFTEEN DAYS <br /> after comp t of ork on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL ARI E RE ORT o the well and,nottfy_ them_before putting.the..well. in use... The above <br /> informa o ue the_best of my.knowledge and belief. I WILL CALL FOR A GR INSPECTION <br /> PRIOR TIN D F N � ECTION. - <br /> SIGNED TITLE Q iA 1_� <br /> W_PLOT PLAN ON REVERSE SIDE <br /> FOR EPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE a /.4, >N�ADDITIONAL COMMENTS:PHASE GROUT INSPECTION ` P III NAL INSPECTI <br /> INSPECTION BY DATE INSPECFT`I,OfN� BY <br /> E 9 1426 Rev. �� <br /> 1-74 SFr hZ75 -2m ' <br />