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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. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date issued 1 >l-?z <br /> 4 (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 Joaqui€ <br /> i County Ordinance No. 1862 and the Rules W Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ' CENSUS TRACT <br /> Owner's'Na Phone ' s <br /> Address 44 7" <br /> f Cit <br /> Contractor's Name <br /> License3 73Phone,4�_ e <br /> 5 <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN '/7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTAL TIO /% PUMPPAIR /7 P REPLAC NT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWERLINBS v#IT 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 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 Pr_otect_ion Rotary -.Type -of Grout <br /> Disposal 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 = L <br /> PUMP .REPAIR: /7 :State Work Done <br /> DESTRUCTION OF WELL: Well Diameter ' Approximate Depth <br /> Describe Material and Procedure <br /> 11 hereby agree toycomply with all laws-and ,regulations of the San Joaquin- Local Health District <br /> land the State of California pertaining to or regulating well-'construction. Within FIFTEEN DAYS <br /> after completion of my work on anew 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 GROUTING AND A FINAL INSPECTION <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID �� �� ,., �M <br /> k I <br /> FOR DEPARTMENT USE ONLY <br /> PHA <br /> APPLICATION ACCEPTED BY _ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II G OUT INSPECTION PHA I F7TAL INSPECTION <br /> i. INSPECTION BY DATEINSPECTION BY ATE <br /> r- - <br /> E H�1426 Rev. 1-74 m 1"/?� ->M <br /> E Fr <br />