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SAN JOAQUIN LG ,2`ffRALTH DISTRICT <br /> FOH OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone • (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> lZgZ D THIS PERMIT EXPIRES 1 YEAR. FROM DATE ISSUED Date Issued 'Y <br /> (Complete In Triplicate) - <br /> Application is hereby ma e to the San Joaquin Local health District- for a permit to construct <br /> and/or install the work h vein described. This application is made in compliance. with San Joaquin] <br /> County Ordinance No. 186,2 d the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS['LVCftTtON 67,G _ : rrS ^�� T �� CENSUS TRACT <br /> . :. <br /> Owner's Name (� Phone <br /> Address .. City <br /> Contractor'-s Name. 1'l�Il,S' L License Phone ' <br /> TYPE ,QF3 WORK. (,Check) : NEW WELT; INI' DEEPEN`,/ j. RECONDITION / / DESTRUCTION /^] _ <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT <br /> Other -/ <br /> DISTANCE TO NEAREST: SEPTIC' TANK lad -�-SEWER LINES &7�PIT PRIVY <br /> SEWAGE DISPOSAL I•ELD�,. at <br /> SEWAGE PIT - —OTHERS` <br /> PROPERTY LINIQ`PRIVATE DOMESTIC WELL --- PUBLIC DOMESTIC WELL _ �y <br /> INTENDED USE TYPE OF WELL ti CONSTRUCTION SPECIFICATIONS V. <br /> Industrial ` Cable t661_ °" Dia, 'of-Well Excavation "el, <br /> Domestic/private `�_CDr-illed=� F -, Dia-.-of .Well-Casing <br /> , Dome•sti:c/pub.li.c _Driven , _ Gauge of Casing ./� <br /> Irrigation ` Gravel`Pack Depth of Grout Seal <br /> Cathodic Protection, Rota Rotary Type of Grout <br /> Disposal. Other Other Information �. <br /> Geophysical Surface Seal Installed By : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT; / / State Work Done , <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter ti . , Approximate Depth <br />` Describe Material and Procedure <br /> -_ - <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, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before puttingthe 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 GROUTING AND A FINAL INSPECTIO <br /> SIGNED <br /> _CMMVPLOT PL REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE •-, "1 OR <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT -INSPECTION PHASE II /FINAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY " . DATE <br /> 2M <br /> E H 1426 Rev. 1-74 <br /> 4 <br />