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LG' dL/� �' � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> rFON;OfflirtE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 .1•���J�. <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 Joaquir <br /> E.County Ordinance;No'. 1862 and the, Rules and Regulations of the San Joaquin Local Health District. <br /> .TOB ADDRESS/LOCATION !• T '�� f CENSUS TRACT " . <br /> 'Owner's Name .X, Phone <br /> Address City ' - ? <br /> or <br /> Contractor's Name License # f3 7 hone c <br /> t l <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /7 RECONDITION f7 DESTRUCTION /_ <br />' PUMP INSTALLATION / / PUMP REPAIR '/ PUMP REPLACEMENT <br /> Other / <br /> i <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 /> Domestic/private Drilled Dia. of Well. Casing <br /> Domestic/public Driven Gauge of Casing <br /> i Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 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 <br /> PUMP ,.REPAIR: / / State Work Done , ae O ? ,��, <br /> DESTRUCTION OF WELL: Well :Diafineter Approximate Depth <br /> Describe Material .and Procedure <br /> I hereby agree to comply with all laws and regulations offthe San Joaquin Local Health District <br /> ff and the State of California pertaining to or '.regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work onfa 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.. ow edge nd belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO ING AND A FIX E I . <br /> SIGNED - TLE <br /> + v RAW PLOTIPLAN ON FRSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> kAPPLICATIOP ACCEPTED BY ` DATE. . <br /> ADDITIONAL- COMMENTS: <br /> PHASE II GROUT INSPECTION- PHASE . I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 7S <br /> .. <br /> ti <br /> E Hs1426 Rev. 1-74 r - 1/75 2M <br />