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SAN JOAQUIN LOCAL, HEALTH DISTRICT <br /> i <br /> 7—FO-F.-'OFFICE USE 1601 E. Hazelton Ave. , •Stockton, Calif. .r <br /> Telephone: (209) 466-6781 doo:e.- <br /> k <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT ermo, 77 -3S"6�, <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 /> JOS ADDRESS/LOCATION ,� �-S� CENSUS TRACT - <br /> Owner's Name -C� �� �� Phone y' <br /> Address 4:5;7:��IS- 5 City <br /> Contractor's Name Licensees Phone <br /> TYPE OF WORK (Check): NEW WELT /_7 DEEPEN / / RECONDITION /7 DESTRUCTION /7 <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 a <br /> INTENDED USE TYPE OF WELL 'CONSTRUCTION SPECIFICATIONS <br /> Industrial -Cable Tool n Dia. of Well Excavation. _ <br /> Domestic/private Drilled' Dia. of Well Casingf <br /> Domestic/public Driven - Gauge of Casing <br /> Irrigation -Gravel-Pack Depth of Grout Seal. <br /> Cathodic Protection Rotary =- Type of Grout <br /> Disposal j Other, _ -Other Information <br /> Geophysical ' Surface Seal Installed By: <br /> PUMP INSTALLATION: <br /> Contractor <br /> Type of Pump H.P. _! <br /> PUMP REPLACEMENT: State Work Dane <br /> PUMP .REPAIR: / / State Work Done <br />,DES,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 bistrict <br />� and the State._of California_pertaining-.to.or„re.gulating,,.well:construction.; Within FIFTEEN DAYS <br /> after completion of my wlork`,on a.new wiell„ I,will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS-REPORT of"the'well and notify-them before7putting-the7well: in- use.—The above <br /> i. information is true to the best of my knowledge and belief. I WILL CAL& FOR A GROUT INSPECTION <br /> PRIOR TO MUTING AU A ZINAL INSPECTION. <br /> SIGNED -' " TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br />� APPLICATION ACCEPTED BY v " DATE <br /> ADDITIONAL COMMENTS: <br /> PHASEjIf,,ROUT INSPECTION PH4$ELXjI/FIN#L INSPECTION <br /> 1NSPECTION,•$Y Al DATE INSPECTION BY DATE <br /> or <br /> E H 1426 Rev. 1-74 //� <br />