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�FOB OFFICE USE; SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: x(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. y/ <br /> f THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> i <br /> Appli (Complete In Triplicate) Date Issued a <br /> r cation is hereby made to the San Joaquin Local. Flealth Diattict for a permit to Joaquin <br /> co <br /> and/or install the nstruct <br /> work herein described. This application is made <br /> County Ordinance. No. 1862 and the Rules and Regulations of the Sa <br /> n In <br /> Loin cal compliance with San .Toaq <br /> Health District. <br /> .TOB ADDRESSJLOCATION eY��.t•45 <br /> F <br /> Owner's Name CENSUS TRACT Phone �� - <br /> Address ~ • � '�� - � <br /> Contractor's Name City SA-1C/,! <br /> ' -P-mi License # Al, Phone <br /> TYPE OF WORK (Check): NEW WELL DEEPEN _ <br /> /? RECONDITION /? DESTRUCTION /7 <br /> PUMP INSTIO <br /> ALLATN PUMP REPAIR /-7PUMP REPLACEMENT <br /> Other /% _ /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK ff1 SEWER LINES <br /> SEWAGE PIT PRIVY _ <br /> DISPOSAL FIELD _ CESS OP OL/SEEPAGE PIT- <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL. PUBLIC DOMESTIC WELL <br /> OTHER <br /> �— <br /> INTENDED USE TYPE OF WELL <br /> Industrial Cable Tool. CONSTRUCTION SPECIFICATIONS <br /> Domestic/private Dia. of Well Excavation <br /> Domestic Drilled <br /> Jpublic Dia. Of Well Casing Irrigation Driven Gauge of Casing <br /> Gravel Pack <br /> Cathodic Protection Rotary <br /> Depth of Grout Seal Q <br /> Disposal - Type of Grout <br /> .Geophysical Other Other Information <br /> Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump i <br /> _ H.P. <br /> PUMP REPLACEMENT: <br /> / / State Work Done <br /> PUMP .REPAIR:--- - -� .L-7 -State Work Done _ <br /> PE,SMUCTION OF WELL: Well Diameter <br /> Describe Material and procedure t Approximate Depth <br /> I hereby agree to comply with all laws and regulations ..........othe San .Toaquin Local,�Health.Distri <br /> and the—state—of—California pertaining to or regulating well canstruction.='Within FIFTEEN DAYS <br /> after completion of my work ones 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.. <br /> Information is true to the-best-of- myknowledge and belief. The above <br /> PRIOR TO G UTING ANDA FINAL INSPECTION. g I WILL CALL FUR A GROUT INSP$CTION <br /> SIGNED <br /> TITLE <br /> Y <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I` FOR DEPARTMENT USE ONLY <br /> ADPL CI ATION ACCEPTED BY . <br /> ADDITIONAL COMMENTS: DATE - <br /> PHAS II GROUT INSPECTION � �^W <br /> INSPECTION BYif,,;�U` t, DATE FHAS III FINAL INSPECTION <br /> --- ` .I--7 7 INSPECTION BY _. DATE <br /> E H 1426 Rev. 1-74 ,. <br />