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r Lv SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR,OFFICE USE: V 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 7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Eealth 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.11862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner Q s Name �_ �!/r/ a Phone�i_J 1 1-/-e 9' <br /> Address City <br /> Contractor's Name License <br /> Ph <br /> S one <br /> 3YPE OF WORK (Check): NEW WELL -/ZT—`DEEPEN ./-7 RECONDITION /_ DESTRUCTION f7 <br /> PUMP INSTALLATION / 'PUMP REPAIR /-7 PUMP REPLACEMENT /7 <br /> Other E7 <br /> 0. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 7,.�— PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER �n <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL v( <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Viable Tool Dia. of Well .Excavation <br /> Domestic/private Drilled Dia. of Well Casing _ � Q41 <br /> -_ Domestic/public Driven Gauge of Casing1-1 <br /> - <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout _ _� ilC <br /> Disposal • _ Other Other Information <br /> F <br /> Geophysical Surface Seal Installed By• �' <br /> PUMP INSTALLATION: Contractor <br /> r <br /> Type of Pump H.P. / <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP. .REPAIR: /7 State Work Done <br /> ES:TRUCTION 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 the-well in .use.. The above <br /> information is true to the-best of: my knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GR AND A FINAL INS ION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SI <br /> FOR DEPARTMENT USE ONLY I <br /> PHASE I <br /> APPLICATION ACCEPTED $Y:'�` "���_� DATE <br /> r �_ <br /> ADDI�S }NAI{:COMMENTS: 1 <br /> # PHASE I GRO T INSPECTION P S ZI INAL TNSPECTION <br /> INSPECTION BY DATE - t INSPECTION BY ATE <br /> a <br /> ;µE H 1426 Rev. 1.-74 �� 1-74 2M <br />