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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO ,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.'7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued(a <br /> (Complete In Triplicate) <br /> Application 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 Joaquin ; <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District, i <br /> .TOB ADDRESS/LOCATION �dD o CENSUS TRACT <br /> ---- - <br /> Owner's Name IRAQ Phone I <br /> Address City <br /> Contractor's Name � �� License # Phone <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN -/7 RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION /T-7—PUMP REPAIR /7 PUMP REPLACEMENT f7 <br /> Other !! —` <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOQSEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <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 Seal <br /> Cathodic Protection 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: /7 State Work Done _ <br /> ,_ES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Y 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 /> 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 <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU G AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: el <br /> PHASE II GROUT INSPECTION PHASE IIYRINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY - DATE Y <br /> 1 E H 1426 • Rev. 1-74 1-74 2M <br />