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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 _ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.2 -Z 1�7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 nd R lations of the San Joaquin Local Health District. <br /> JOB ADDRESS LOCATION �� 9, CENSUS TRACT <br /> Owner's Name U U 1 t � Phone <br /> Address ✓ t' ""_ "' city <br /> Contractor's Name ' /" �"l License 3Phone ��l� <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR X PUMP REPLACEMENT /-7 <br /> Other <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 Excavation <br /> i/Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 's <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 /> - <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done( � T <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> r <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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE �n <br /> D iAWPL T PLAN ON RE ESE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Q <br /> APPLICATION ACCEPTED BYft&� DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE -�Z <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />