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SAN. JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. , <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 /> J 1 <br /> JOB ADDRESS/LOCATION (�G Uy �f1 ar n. °I �a�+. (/C�J <br /> � 13 CENSUS CENSUS TRACT <br /> --- f Owner's Name /'C e/I'K e / a 4d- Phone -:2 <br /> Address - - - { �-• o+"_ �4 ( City ^ a? <br /> i <br /> Contractor's Name ; f License # Phone <br /> I <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN/ / RECONDITION /_7 DESTRUCTION ` <br /> PUMP INSTALLATION/—/ PUMP REPAIR / / PUMP 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 <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 B : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,.REPAIR: / / State Work Done a <br /> & ` <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Erocedure h P <br /> d v 7L0V x2.j` C, <br /> I hereby agree to comply with all laws and reguXAtikns. of the San Joaq 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 G TING A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> F R DEPARTMENT USE ONLY <br /> PHASE I <br />' APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P E IJII/ INAL INSPECTION <br /> JNSPECTION BY DATE INSPECTION BY DATE 3l <br /> N IL9A moo„ 1_74 <br /> UZ7 2M <br />