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-- <br /> SAN JOAQUI6 LOGW, HEALTH DISTRICT i <br /> YO—R!OFFICE USE; 1601 E. Hazelton oe. , 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 .3 ar- <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 /> 6Do 3 cjft- ,01<ee <br /> JOB ADDRESS/LOCATION.. ' .� CENSUS TRACT p 2-- <br /> Owner's <br /> Owner's Name _ �° �.. ._... Phone l' 91/d { <br /> Address - City _ <br />`��ntractor's Name <br /> License # h2d q Phone <br /> v <br /> TYPE OF WORK (Check): NEW WELL L� DEEPEN '/'7 RECONDITION /7 DESTRUCTION f-7 <br /> 'PUMP INSTALLATION / / PUMP RE ./ <br /> PAIR- 7 PUMP REPLACEMENT <br /> Other /-7 C" — _..- <br /> ' ,F .0 <br /> DISTANCE TO NEAREST: SEPTIC--TANK-71&" 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 . , a ' CONSTRUCTION SPECIFICATIONS <br /> Industrial ( Cable Too! Dia—.—di—Well Excavation <br /> Domestic/private DrilledDia. of Well Casing <br /> ft.., <br /> Domestic/public' Driven ;Gauge,of "Casing 1 <br /> y:Irrigation Gravel- Pack s Depth of Grout Seal <br /> Cathodic Protection Rotary _Typeof'.Groiit -. ' . <br /> Disposal Other Other_Information. <br /> gurface_Seal. Installed .BX* <br /> PUMP 'INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: r <br /> State Work Done <br /> PUMP :REPAIR: /-7 State Work Done <br /> ES:'RUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulationa of the San Joaquin Local Health District <br /> and .the State of California pertaining to orregulat,ing 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 notify1hem 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 w <br /> {DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE -I , <br /> APPLICATION ACCEPTED BY DATE y— <br /> ADDITIONAL COMMENTS: <br /> PHASE U G T N E I PHAS I FIN INSPECTION <br /> INSPECTION BY DATE `r INSPECTION BY ATE -`7 <br /> E H 1426 Rev. 1-7.4 J <br /> 1-7A 7M' <br />