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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i(k6 FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR. WELL CONSTRUCTION OR PUMP PERMIT Permit No. G� <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 /> JOB ADDRESS/LOCATION 2- CENSUS TRACT <br /> Owner's Name <br /> l Phone <br /> P <br /> Address City ' <br /> License # Phon <br /> Contractor's Name t <br /> i <br /> TYPE OF WORK (Check) : NEW WELL// DEEPEN '%/ RECONDITION -7 DESTRUCTION /-T <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of -Well Casing <br /> OF Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack - Depth of Grout., Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. i <br /> i <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP .REPAIR: / / state Work Done <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 Distr:rc <br /> llt <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DA 5 ` <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, a above <br /> r information is t ue to the best of .my know edge and belief. I WILL FOR A- OU INSPECTION <br /> PRIOR TO GROUT AND A FINAL ApEarION.1 <br /> SIGNED TITLE <br /> ARAW PI T PL 'ON RE RSE SIDE <br /> FOR D§qRTMENT USE ONLY <br /> r <br /> PHASE IJ 7 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROU1.T INSPECTION PHA III/FINAL INSPECTION <br /> INSPECTION BY DATE !�---�7-j7 INSPECTION BY DATE <br /> 3/76 2 <br /> E H 1426 Rev. -1-74 -- __ <br />