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z; <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F.'R!OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. � <br /> I <br /> Telephone: (209) 466-6781 i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> i <br /> i <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <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 Joaquinl <br /> County Ordinance No. 1862 and the Rs and Regulations of the San Joaquin Local Health District. <br /> 30B ADDRESS/LOCATION CENSUS TRACT <br /> Owner°s Nance Phone <br /> Address <br /> City <br /> Contractor's Name License #-40"Phone LfP;� / <br /> TYPE OF WORK (Check): NEW WELL '/? DEEPEN /? RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION /% PUMP REPAIR /-7 PUMP REPLACEMENT <br /> Other /-7 <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 TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well ExcavationI <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 aj,119 �- <br /> Type of Pump H.P.-, <br /> PUMP REPLACEMENT: / / State Work Donee <br /> PUMP '.REPAIR: I I State Work Done � <br /> i <br /> ESmRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure j <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 notifythem before <br /> putting.the..we11 in use. The above <br /> information is true to the best of my knowledge and belief. I WILL FOR A GROUT INSPECTION <br /> PRIOR TO GRO ING 4MA fINAL INSPECTION. <br /> SIGNED TITLE t <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � ; <br /> APPLICATION ACCEPTED BY lit/� DATE ,? <br /> 76 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASEAIILFINa INSPECTION ; <br /> INSPECTION BY DATE INSPECTION BY ATE <br /> i E H 1426 Rev. 1-74 <br />