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(/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORe'OFFICE USE. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone; (209) 466-5781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued � - <br /> (Complete In Triplicate) i <br /> Applicdtion 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 Joaquini <br /> County Ordinance No. 1.862 and the Rules and Regulations of the San Joaquin .Local Health District. ' <br /> JOB ADDRESS/LOCA ON Y CENSUS TRACT <br /> Owner's Name � Phone 3 L C?,2�'�n0 <br /> Address ,� C <br /> ity _ <br /> Contractor's Name License 111 )_37_? Phone <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN -/-7 RECONDITION /-T DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR J�R .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 <br /> INTENDED USE w ;_� TYPE OF WELL i CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private v Drilled Dia. of Well Casing <br /> Dotmstic/publicIf� Driven Gauge of- Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection t Rotary Type of Grout <br /> Disposal _ # '� I Other Other Information <br /> Geophysical is j Surface Seal Installed By <br /> I ns : <br /> PUMP INSTALLATION: Contractor 'f <br /> :.a <br /> Type of Pump H.P. _ <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP-:'.REPAIR: -State-Work-Done <br /> UCTION_OF WELL: Well Diameter ` <br /> �ES;TR-� , ,,,.. Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agtee 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 above 1 <br /> information is true to the-best of my-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO U NG MDFINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) �. <br /> FOR DEPARTMENT USE ONLY ^` <br /> PHASE I /_ <br /> APPLICATION ACCEPTED BY r DATE �- 2--V <br /> ADDITIONAL COMMENTS: 00I <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -d2 3-7 <br /> > E H 1426 Rev. 1-74 ,_7A lu <br />