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SAN JOAQUIN LOCALHEALTH DISTRICT <br /> FOR(OFFICE USE: / ;i6012E. .Hazelton Ave.. , Stockton, Calif. <br /> Telephoner (209) .466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES'115YEAR FROM DATE ISSUED Date Issued7� <br /> (Complete In Triplicate) �'soiJ t� -f30-SS <br /> Application is hereby made -to' the' San JoaquinjLocal;•�ealth 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 /> Ir JOB ADDRESS/LOCATION ,` y ,�GENSUS TRACT r <br /> Owner's Name Phone <br /> rAddrese d City <br />;�-Contractor's Name License Phone <br /> E� clP <br /> TYPE OF WORK (Check): NEW WELL '/_7 DEEPEN / RE IQQNDITION; DESTRUCTION /-7 <br /> PUMP INSTALLATION ' ` PUMP REPAIR / UMP REPLACEMENT _� <br /> Other /� ``r <br /> I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES/V PIT PRIVY <br /> SEWAGE DISPOSAL FIELD,4%2' CESSPOOL/SEEPAGE PIT OTHER <br /> r PROPERTY LINE +- PRIVATE`EDOMESTIC WELL ` PUBLIC DOMESTIC WELL <br /> INTENDED USEo <br /> E,OF WELL # jN CONSTRUCTION SPECIFICATIONS Q <br /> s Industrial Cable .Tool Dia. of Well Excavation Od <br /> Domestic/private Drilled Dia. of Well Casing <br /> Dia.- i <br /> Domestic/public Driven - .,Gau e-o€ <br /> "' <br /> Irrigation Gravel Pack' Depth° of Grout Seal <br /> Cathodic Protection Rotary F Type of Grout <br /> Disposal Other Information ' <br /> f Geophysical Other Surface Seallnetalled By: I <br /> PUMP INSTALLATIONt Contractor € �` <br /> Type of Pump ;I. H.P. <br /> PUMP REPLACEMENT: L State Work Done <br /> PUMP '.REPAIR: State Work Done <br /> &I S-TRUCTION OF WELL: Well Diameter 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 ,�regulat•ing well construction. , Within FIFTEEN DAYS <br /> after completion of my work on a new well, I Will €uirnish the San Joaquin Local Health Dietr#.ct a <br /> SWELL DRILLERS REPORT of the well and notify them betore 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 GROUTINGAD A FIN INSPECT ON. <br /> SIGNED TITLE <br /> ` DRAW PLOT PLAN'JON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 5 7 s <br /> ADDITIONAL COMMENTS: <br /> F PHASE II.GROUT I SPECTIONI� PHAS FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> I H 1426 Rev. 1-74 1-773'2M . f <br />