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SAN 30AQUIN LOCAL-.HEALTH DISTRICT , <br /> FFOR'-OFFICE USE: 1 �� 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone: (209) �+bb-5781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued2 <br /> i (Complete In Triplicate) F <br /> Application is Hereby made tolthe 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 an Re <br /> , �tions he n Joaquin .Local'Health Dista#ct. <br /> JOB ADDRESS/LOCATION /� . . �✓ LG CENSUS TRACT <br /> ' Phone " <br /> Owner's Name !t t <br /> Address - City <br /> Contractor's Name ' <br /> License C29a�/� Phone ;554r .6G <br /> TYPE OF WORK (Check): NEW WELL DEEPEid '�/ RECONDITION DESTRUCTION T <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT <br /> _ .. Other��/ / f <br />';,DISTANCE TO NEAREST:, SEPTIC TANK a SEWER LINES PIT PRIVY <br /> SEWAGE 'DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> WELL <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL CO STRUCTION STIC SPUBICECIFICATIONS <br /> INTENDED USE TYPE OF WELL / <br /> . k Industrial ! Cable Tool Dia. of' Well Excavation ! \„ <br /> Drilled Dia. of Well Casing �n <br /> Domestic/private <br /> , J Domestic/public t Driven Gauge of Casing <br /> Irrigation <br /> i Gravel Pack Depth of Grout Seal <br /> f Grout <br /> Cathodic Protection a Rotary <br /> ptherpe olnformation <br /> Disposal ' Other _ <br /> out <br /> Geophysical Surface Seal installed B <br /> PUMP INSTALLATION: Contractor H. <br /> Type 'of Pump <br /> PUMP REPLACEMENT: 1 / State Work Done <br /> PU14P••.REPAIR: / / State Work Done <br /> DES°rRUCTION 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 /> i and the State of California .pertaini.ng 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 INSPECT 0 <br /> EPRIOR TO GR UTING .AND A FINAL INSPE ION TIT -ti- <br /> SIGNED (DRAW OT PLAN ON REVERSE SIA <br /> OR DEPART T USE ONLY <br /> PHASE I } r y DATE / <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: . pHAS III FI1AL INSPECTION <br /> PHAS GROU INSPECTION INSPECTION BY ATE <br /> INSPECTION BY F ATE <br /> 177 11/77 2M <br />