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-SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO _-. i 1601 E. Hazelton Ave.., -Stockton, Calif. <br /> i <br /> Telephone (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PE IT er-mit No., ; <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 /> I,. and/or install the work:-herein described. This' application is .made in compliance with ,San Joaquin; <br /> County Ordinance Na. .1862 and the Rules and .Regulations of the San Joaquin Local­ Health District. <br /> .JOB ADDRESS/LOCATION _#S44,CENSUS TRACT <br /> Owner's Name � Phone <br /> Address ®a $ � City <br /> Contractor's Name License # / one s <br /> f <br /> { <br /> 1 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN -RECONDITION-/-RECONDITION_/�/ DESTRUCTION <br /> PUMP INSTALLATION / PUMP REPAIR /J/ PUMP REPLACEMENT /7 <br /> F 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 Qi <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 S ✓ <br /> Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: f' t <br /> PUMP INSTALLATION: Contractor .. <br /> - - -- <br /> Type of Pump 1i H.P. ! t' <br /> PUMP REPLACEMENT: / / State Work Done. <br />} PUMP -ii*A*R-: / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material a-ad' 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, 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... The abovey <br /> information is true to the best of my know-ledge a 1ief. I WILL CALL FOR A GROUT INSPECTION . <br /> PRIOR TO GRO TING AND A FINAL IUN. t <br /> SIGNED TLE <br /> (DRA , PL PL ON REV SE SIDE) - <br /> 0 DEPARTMENT USE ONLY <br /> PHASE I 4 / <br /> APPLICATION ACCEPTED BY' DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II OU INSPECTION PHASE III/FINAL INSPECTION <br /> Y� <br /> INSPECTION BY DATE INSPECTION BDATE �(3 <br /> o,� 7 _ 211 <br /> `�E H 1426 Rev. . 1-74 .� - .... <br />