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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USX: el 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 W <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -Sad <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 and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> SUS TRACT <br /> Owner`s Name — Phone <br /> Address <br /> 0 City <br /> Contractor's Name10 Ae f7 <br /> License # Phone . �1 % <br /> TYPE OF WORK (Check) : NEW WELL /77;". DEEPEN / / RECONDITION_/ / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / I PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 34aQ1 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 /> j Industrial Cable Tool Dia. of Well Excavation �� <br /> f._ Domestic/private Drilled Dia:yof'Well Casing, /r 4 <br /> Domestic/public,. -Driven . . �6au.ge. of�Casing, ,,.�.; 454_ v a f <br /> Irrigation Gfavel Pack Depth of=Grout Seal <br /> Cathodic Protection �_ Rotary Type of Grout ' r' <br /> Disposal Other Other Information" — G <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe �Material and Procedure a <br /> _,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 /> ,WE'LL 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 G UTING AND A INAL I PECT ON. ' <br /> TITLE <br /> SIGNED <br /> PLAN''ON RE SE SIDE) > ;'I: <br /> DEPARTMENT USE ONLY <br /> PHASE I ' <br /> DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P IIIINAL INSPECTION <br /> � INSPECTION BYE DATE INSPECTION BX .,. ,z� DATE l <br /> E H 1426 Rev. 1-74 <br />