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iSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i FOF�rOFFICE USE. �� 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ' Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z_4116.1 <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Appiicdtion 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 Joaqui <br /> County Ordinance No, 1862 and the.Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> k Owner's Name <br /> Phone Q <br /> i Address <br /> City <br /> Contractor's Name <br /> f License hone <br /> TYPE OF WORK (Check) : NEW WELL/ V DEEPEN�/�RECONDITION Lf DESTRUCTION / f <br /> PUMP INSTALLATION /'?" PUMP REPAIR1_7 Pip REPLACEMENT <br /> j Other <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES <br /> �."'' PIT PRIVY <br /> 'SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE PRI VA D0 M9 C':.WELL". `. FUBLIC--DOMESTIC WF�L-L --- <br /> - INTENDED USE TYPE OF LL ,. CONSTRUCTION,SPECIFICATIONS <br /> nd�cstrial able Took. -Dia. Of Well Excavation <br /> Domestic/private .. Drilled Dia. of Well Casing <br /> `Domestic/public <br /> Driven �.- Gauge of Casing p � , <br /> - Cat <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> �,Disnodic Protection Rotary _. Type of Grout ___- <br /> _. <br /> Disposal _ Other <br /> Geophysical _ _ -- Other Information <br /> Surface Seal Installed <br /> PUMP INSTALLATION: ContractorF <br /> . <br /> Type of Pump H.P. Q <br /> PUMP REPLACEMENT: , / / State Work Done <br /> k y <br /> PUMP '.REPAIR: a L ,` <br /> State Work Dorie '' � . . . <br /> DESTRUCTION OF WELL: Well Diameter ..�- <br /> Describe Material and Procedure Approximate Depth <br /> 11 hereby agree to comply with all laws and regulations of the Sats Joaquin Local Health District (� <br />+ and the State of California pertaining,to or regulating well ''construction.. Within FIFTEENy <br /> after completion of my work oii`a new well'71- will furnish, the San ,Joaquin Local Health DistrAYS <br /> ict 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. . <br /> PRIOR TO GROUTI D FIN SPE ION. <br /> I WILL CALL FORA GROUT INSPECTION <br /> G <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> EP� SE I FOR DEPARTMENT USE ONLY <br />' APPLICATION ACCEPTED BY �' <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION PHASE_!"I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> • - DATE -1-6- <br /> E <br /> SE H 1426 Rev. 1-74 <br />