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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 0—R76FF10E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3ylJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issue <br /> d ,.:Zrf <br /> i! (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 /> i <br /> JOB ADDRESS/he&Vff ' t Q rdi r CENSUS TRACT <br /> Owner- Is Name <br /> !,r.,.x°.�1�Y ��[f� ---. Phone <br /> Address City . <br /> Contractor's Name / License # Phone <br /> TYPE OF WORK (Check): NEW WELLN� / /y DEEPEN /'7 RECONDITION /? DESTRUCTION /7 <br /> _ - -PUMP INS TION REPAIR -PUMPwREPLACEMWNT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK --SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSA FIELD CESSPOOL/SEEPAGE PIT -4--OTHER <br /> PROPERTY LINE/--"PRIVATE DOMESTIC WELL3-E- 0 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 /> 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 BY: <br /> PUMP INSTALLATION; Contractor �. . <br /> _ a Type ',of Pump 1 H.P. <br /> PUMP REPLACEMENT: %/ iState Work Done <br /> .PUMP `REPAIR: -- /7 State Work Done <br /> ES: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, 1 -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 GROUTIQG ANDA FINAL INSPECTION. <br /> SIGNED TITLE /'° . . ,, ,: <br /> DRAW PLOT PLAN ON REVERSE SIDE -- <br /> PHASE FOR DEPARTMENT USE ONLY ' <br /> PRASE I <br /> APPLICATION ACCEPTED DATE g <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE -/J- 7! INSPECTION BY DATE a - <br /> E H 1426 Rev. 1-74 1-74 2M } <br /> ._�. <br />