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WM SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 /> F <br /> JOB ADDRESS CENSUS TRACT <br /> I <br /> Owner's Name 111,14P Ib Phone <br /> Address , City <br /> Contractor's Name r l A60S License Phone. <br /> TYPE OF WORK (Check): NEW WELL / Q DEEPEN ,/-7 RECONDITION /-7 DESTRUCTION 1 <br /> PUMP INSTALA�TION PUMP REPAIR / / PUMP REPLACEMENT f <br /> Other f-1 <br /> DISTANCE TO NEAREST: SEPTIC TANK PSEWER LINES IT PRIVY <br /> SEWAGE DISPOSALIELD , �,/SEEPAGE PI�41f'OTHER --� <br /> PROPERTY LIN PRIVATE DOMESTIC WELL = PUBLIC DOMESTIC WELL /�.�e <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS C1. <br /> Industrial Cable Tool Dia. of Well Excavation <br /> �C Domestic/private - � Drilled Dia. of Well Casing . r� <br /> Domestic/public Driven Gauge of Casing I I IC./ /jjg 4ze- <br /> Irrigation Gravel Pack Depth of Grout Seal 9M2 -f7 4 <br /> Cathodic Protection Rotary Type of Grout ,j�l <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. _ <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP-BEPAIR: /7 State Work Done <br /> ,RES 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 FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED T TIT <br /> X; <br /> DRAW PLOT PLAN ON REVERSE <br /> PHASE I <br /> FO PARTMENT SE ONLY <br /> APPLICATION ACCEPTED BY DATE 6 <br /> ADDITIONAL COMMENTS: <br /> PHASE. II GROUT INSPECTION PHASW/-2I1/FINU INSPECTION <br /> INSPECTION BY 12-1 9 DATE INSPECTION B A& DATE - S <br /> E H 1426 Rev. 1.-74 1-74 2M <br />