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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORIOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6-/1-7 <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. <br /> :26 /VS <br /> JOB ADDRESS/LOCATION CENSUSCT <br /> Owner's Name11 �' v 4 Z Phone &7— <br /> Address <br /> � <br /> city :5.Ca <br /> Contractor's Name �C 2i� ,.,� License #, Phone <br /> TYPE OF WORK (Check): NEW WELL /'7 DEEPEN '/_7 RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / f PUMP REPAIR /7 PUMP REPLACEMENT <br /> other /_1 <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 "1 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled ilia. 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 j ' Other Other Information <br /> Geophysical Surface Seal Installed B : <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 /> 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 FORA GROUT INSPECTION <br /> PRIOR TO GROUTIM AND A FIOL IN PECTION. <br /> SIGNED &A 4cdTITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PRASE T �. ��� <br /> APPLICATION ACCEPTER BY 4 -� � DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYDATE -2 3r� <br /> f <br /> �� �E R 1426 Rev. 1.--74 1-74 2M <br />