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SAN JOAQUIN LOCAL HEALTH STRICT <br /> FOF "OFFICE USE: 1601. E. Hazelton Ave. , Stockton, Calif. Iv <br /> _ Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 1-7-02- <br /> f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> I (Complete In Triplicate) 1,0.0 --, <br /> Application is he y made to the San Joaquin Local Health District for a permit to con trust r <br /> and/or install e work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. -862 and the Rules and Regulation f the San Joaquin Local Health District. i <br /> 6. <br /> JOB ADDRESS/LOCATION p D UXVjRACT { <br /> Owner's Name _ p a s- Phone <br /> Address City 42Q Al <br /> T <br /> Contractor's Name go <br /> License 43 Phone l - / <br /> 1 <br /> TYPE-OF-WORK-(Che-ck)-:--NEW -WELL-X—DEEPEN­/7-/ RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /7 ' <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK .+SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL MELD CESSPOOL/SEEPAGE PIT OTHER -� <br /> PROPERTY LIN PRIVATE DOMESTIC WELL _ fPUBLIC DOMESTIC WELL <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 Casing4a An' <br /> ! <br /> Irrigation Gravel Pack Depth of Grout Seal- <br /> Cathodic Protection Rotary Type of Grout 1 <br /> Disposal Other Other Information { <br /> Geophysical _ -�--Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor""�'-""`'�f <br /> 644 <br /> Type of Pump H.P., Z , -- <br /> PUMP REPLACEMENT: / / State Work Done <br /> i <br /> PUMP .REPAIR: /7 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 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 thewellin use. The above <br />" information is true to th rlN9p, <br /> of , knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />,PRIOR T OUTING D A F <br /> SIGNED TITLE ¢^�� <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ; <br /> APPLICATION ACCEPTED BY DATE 7 J <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION, BY L✓ DATE <br /> 1177 2M <br /> E H 1426 Rav- 1-7G <br />