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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR 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 :y Date Issuedj� <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 with­San Joaquin <br /> County Ordinance No. 11862 and the Rules and Regulations of the San Joaquin Local Health District. - <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name L2---x ,-y # 1 Phone <br /> Address o 6 Cit <br /> Contractor's Name License # I6o73�J Phone <br /> TYPE OF WORK (Check): NEW WELL/-7 DEEPEN / / RECONDITION_0 DESTRUCTION /7 <br /> PUMP INSTALLATION/ / PUMP REPAIR PUMP REPLACEMENT /? <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 Q <br /> Irrigation Gravel Pack Depth of Grout Seal p <br /> Cathodic •Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical T <br /> Surface Seal Installed By: <br /> i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done . ._. <br /> PUMP 'REPAIR. /7"—State"Wo'rk"Done <br /> ➢EF. <br /> ;,§TRU_CTION OF WELL: Well Diameter � Approximate D pth <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 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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> P)KAWMT PLAN ON RE EkSE SIDE) <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE j <br /> ADDITIONAL COMMENTS: <br /> PHASE II G I 5 CTION PHASE III/FINAL INSPECT,40N <br /> INSPECTION BYATE INSPECTION BY k-�- :;Zf _ �-�{;� DATE <br /> - <br /> 4 E H 1426 - Rev. 1-74 - x V- - <br /> 3/76 ' 2M <br />