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USE: SAN JOAQUIN LOCAL, HEALTH DISTRICT " <br /> FOR_ OFFICE 1601 E. Y <br /> Hazelton Ave*', Stockton, Calif. <br /> Telephone: i�(20g) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I YEAR <br /> f FROM DATE ISSUED Date Issued <br /> 4 <br /> Application is hereby made to the San (CompletIn e <br /> Local rHealth District fora permit <br /> k and/or install -the work herein described. This application is made in compliancetwithnSanuJt <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> E' JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name <br /> r <br /> Phone �7�� <br /> Address Q'� \ - . <br /> �� O• � _`1.ti : �� � City <br /> Contractor's Name <br /> License Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN <br /> /_/ RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION L/ PUMP REPAIR / / PUMP REPLACEMENT /� <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANKLIN <br /> • SEWAGE DISPOSALFIELD WER ES PIT PRIVY ; <br /> CE SPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE RIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL <br /> Industrial CONSTRUCTION .SPECIFI('ATIONS <br /> Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled <br /> Domestic/public r Dia, of Well Casing <br /> Driven Gauge •f,Casin' �� <br /> Irrigation Gravel Pack E \ <br /> Cathodic Protection Deptho`f Grouts Seal t - <br /> - Rotary Type �of Grout 3 <br /> Disposal Other Othei Information ; <br /> Geophysical "-' � � .,..�- ► <br /> Surface�•Seal Installed B <br /> PUMP INSTALLATION., Contractor <br /> Type of Pump <br /> ` H.P. <br /> PUMP REPLACEMENT: <br /> State Work Done <br /> PUMP .REPAIR: t <br /> / / State Work Done ; <br />)ES-TRUCTION OF WELL: Well Diameter !! f € <br /> Describe Material a d Procedure — Approximate Depth _` <br />[ hereby agree to complyr <br /> with all laws and regulations of the San io7a_qyi�nLocal Health District <br /> and the State of California pertaining to or regulating well '.construction. Within FIFTEEN DAYS <br /> if ter completion of my work on a new well, I'�wiil furnish the San Joaquin Local Health District a , <br /> BELL DRILLERS REPORT of the well and notify them before putting the -well in use. The above <br />_nformation is true to the best of my knowledge and belief. <br /> RIOR TO GROUTING,AND A FINAL INSPECTION. I WILL CALL FOR A GROUT INSPECTION'" <br /> SIGNED <br /> TITLE <br /> D W PL,T PLAN 'ON RE FRSE SI <br />'HASE'i FOR DEPARTMENT USE ONLY <br /> PPLICATION ACCEPTED BY <br /> DDITIONAL COMMENTS: DATE - <br /> P I 0 T INSPECTI PHASE III/FINAL INSPECTION <br /> NSPECTION BY _DATE INSPECTION $Y <br /> ` /.,g &ell --- DATE <br /> E H 1426 Rev. 1-74 3/76 2M <br />