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�q U 15 o ,n 1� ; <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Zf__19 3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Y��' <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct e <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 o t e San Joaquin Local Health District. <br /> i <br /> JOB ADDRESS/LOCATION � ' CENSUS TRACT ' <br /> Owner's Name Phone <br /> Address <br /> Contractor's Name License #.'IA6 7<10 Phone f <br /> f <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION UMC' 'REP IR / / PUMP REPZACEMENT f_ l <br /> } Other <br /> DISTANCE :TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY _ r . <br /> SEWAGE DISPOSAL FIELD .' CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELZ PUBLIC DOMESTIC WELL - <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS n/ <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 T r ` <br /> Cathodic Protection Rotary Type of Grout <br /> _-Disposal `Other Other Information <br /> Geophysical Surface Seal Installed By: 67i/� _ t <br /> PUMP INSTALLATION: Contractor. . <br /> Type .1of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done ! <br /> PUMP REPAIR: - - f�� f --State Work Done <br /> DESTRUCTION OF WELL: Well Diameter - s 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 /> I after completion of my work on a new well., I will furnish the San,Joaquin Local Ii ealtli, District a <br /> WELL DRILLERS REPORT of the well and notify them before putting thewell 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 94OUTING AND aINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �v DATE <br /> ADDITIONAL COMMENTS: <br /> i PHASE II GROUT INS CTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY �^ DATE -T <br /> 6777 . 2ND <br /> E--H- 1426 Rev. . 1-74 <br />