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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> s FOF, 1OFFICE USE: 1601 E, Hazelton Ave_. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP .PERMIT Permit No.�7 <br /> O$-?It) <br /> h �1^ THIS' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> aro (Complete In Triplicate) Date Issued <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 Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ' 4/ �. <br /> CENSUS TRACT <br /> Owners Name <br /> Phone <br /> Address �- f. q � ! / <br /> City <br /> Contractor's Name <br /> Ikicense_#;1t261 Phone�:T.,g4t_7, <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN _ - <br /> ,� / / RECONDITION / / DESTRUCTION /� <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT <br /> Other / / �,. <br /> DISTANCE TO NEAREST: SEPTIC TANKS <br /> EWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL, CONSTRUCTION SPECIFICATIONS <br /> Industrial f 7 Cable Tool Dia, of Well Excavation <br /> I,,*-- Domestic/private Drilled Dia, of Well Casin � <br /> Domestic/public Driven g �� 0— <br /> Irrigation Gauge of Casing <br /> Gravel Pack Depth of Grout Seal F <br /> Cathodic Protection Rotary Type of Grout G <br /> Disposal OtherOther Information <br /> Geophysical ""--- <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: <br /> Contractor = 3. <br /> Type of Pump ; <br /> H.P. ' <br /> PUMP REPLACEMENT <br /> / / State Work Done <br /> PUMP .REPAIR: � _ <br /> / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with all laws and .regulations of the San Joaquin. Locaj 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 OUTING AND A FTN�' INSPECTION. <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSETLE <br /> SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY � <br /> ADDITIONAL COMMENTS; <br /> DATE <br /> PHASE II GROUT I SPECTION PHASE III/FINAL I PECTION <br /> INSPECTION BY DATE INSPECTION BY GCS <br /> E H _1426 Rev. • 1-74 <br />