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k01 <br /> �SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFi,OFFICE USE. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL. CONSTRiCTION' OR PUMP PERMIT Permit No. ZZ_ <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 Health District for a permit to construct <br /> i and/or install the work herein described. This application is made in compliance with San Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local -Health District. <br /> JOB ADDRESS/i&e*T= �/ CENSUS TRACT <br /> Owner's Nam - � Phone ' <br /> iM <br /> Address City ' <br /> Contractor's Name License Phone o <br /> TYPE OF WORK (Check): 1'NEW WELL DEEPEN '/7 RECONDITION /-7 DESTRUCTION f 7 <br /> ! PUMP INSTLATION PUMP REPAIR /_7 PUMP REPLACEMENT /'? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY -� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT / QZ�-OTHER <br /> = PROPERTY LINE/4*RIVATE DOMESTIC WELLDOMESTIC WELL_= \ <br /> INTENDED-USE--�_. '—'TYPE--OF WELL-` CONSTRUCTION SPECIFICATIONS <br /> Industrial. � Cable Tool Dia. of Well Excavation t / <br /> Domestic/private: _ ,y Drilled Dia. of Well Casing ! // <br /> Domestic/public -"7"�- Driven Gauge of Casing t <br /> Irrigation Gravel Pack Depth of Grout Sea] _ n . <br /> Cathodic'Protection _„ Rotary Type of Grout f f <br /> Disposal - - Other Other Information <br /> Geo h s:ical.', ." : , --------- <br /> P �' Surface Seal Installed By: <br /> PUMP INSTALLATION: oniractor <br /> . - -- - <br /> Type-of-Pup-.. .. _ ------ ----- - __�_- • . H.P. <br /> PUMP REPLACEMENT: . State Work Done <br /> 'PUMP .REPAIR: <br /> / :State Work Done <br /> ;.1 <br /> DESTRUCTION 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 mywork 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>,Ithe.best-of .my..knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A'' VINAL INSPECTION. ' / <br /> SIGNED 1� TLE (/� <br /> i�. PLO P N REVERSE SIDE <br /> /_ <br /> DEPAltTMENT USE ONLY <br /> PRASE I �. <br /> APPLICATION ACCEPT O TATE '- - <br /> ADDITIONAL COMMENTS <br /> 6 Of 412477 <br /> PHASE II GROUT INSPECTION PHASE FIN INSPECTION <br /> INSPECTION BY `` DATE 1,7 INSPECTION BY ATE. <br /> t E H 1426 Rev. 1-74 .ti 1r/75 2M <br />