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FOB-:OFFICE USE: SAN JOAQUIN LOCAL HEALTH DISTRICT' . <br /> f 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 <br /> (Complete In Triplicate) Date Issued <br /> Applicat —26 <br /> ion is hereby made to the San Joaquin Local. Health District for a permit t <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 <br /> o construct. <br /> ADDRESS/LOCATION 1 Health District. <br /> • I•f�� �� ' CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address lrp <br /> City.� --�._ <br /> Contractor's Nam . A) <br /> License Q&[Q Phone <br /> d <br /> TYPE OF WORK (Check): NEW WELL -/7 DEEPEN <br /> /� RECONDITION /_7 DESTRUCTION - u <br /> PUMP-.INSTALLATION <br /> s"'- PUMP REPAIR - . PUMP REPLACEMENT <br /> Other /% /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES FIT PRIVY <br /> SEWAGE DISPOSAL FIELD _ <br /> PROPERTY LINE - PRIVATE DOMESTIC Sy,TELI, SEEPAPUBLIC D T OTHER <br /> INTENDED USE TYPE OF WELL IC WELL <br /> Dia �n�r <br /> ^� Industrial Cable Tool � .. CONSTRUCTION SPECIFICATIONS �I� <br /> Domestic/private . of Well Excavation <br />_ Domestic/public ---- Drilled Dia. of Well Casing <br /> Irrigation DrivenGauge of Casing <br /> f Cathodic Protection Gravel Pack Depth of Grout Seal <br /> -�` Rotary <br /> Disposal -�� Type of Grout F� <br /> Geophysical. Other4 Other Information- . <br /> Surface Seal'Installed •B <br /> PUMP INSTALLATION. Contractor <br /> it <br /> Type of Pump <br />'UMP REPLACEMENT: D.P. / --- <br /> / / State Work Done <br />'UMP :REPAIR: <br /> State Work Done - <br /> E&TR�ON OF WELL: Well Diameter <br /> Describe Material andProcedure Approximate Depth <br /> a <br /> hereby agree to comply with all laws and regulations of theSari Joaquin Localr <br /> nd the State of California pertaining to or regulating well,"construction.\- Wi.thin'FIFTEENtDAYS <br /> fter completion of my work on anew well, I will furnish the San Joaquin Local <br /> ELL DRILLERS REPORT of the well and notify them before Putting.. the�-the.' -.`�eTh6 above <br /> rict <br />(formation is true to the-best .of_my..knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />'kIOR TO GRO TING AND A FINAL INSPECTION. N <br /> CGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br />[ASE I EPART T USE ONLY <br />'PLICATION ACC <br /> IDITIONAL 'COMMENTS: dAG//UQ7`Y/ DATE <br /> PHASE II GROUT INSPEGTION PHA E I FINAL INSPECT ON <br /> SPECTION $Y DATE <br /> INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br /> _.. r� <br />