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SAN JOAQUIN LOCAL HEALTH DISTRICT ._. . <br /> F0 r F f� <br /> Fs fl F'ICE USE. 1601 E. Hazelton. on Ave. , Stockton, Calif. SCOADf ,/ <br /> Telephone: (209) 465-6781 7 "`�� <br /> APPLICATION FOR WELL CONSTRUCTION OR PMP PERMIT Permit No. 5�3r�vl� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued - 75 <br /> 3 (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 �� CENSUS TRACT <br /> Owner's Name Phone � a - 1-3 <br /> Address' City <br /> I <br /> Contractor's Name -�. -•-_rr _ .. License-4.2 19CClo-OC226 <br /> TYPE OF WORK '(Check):- NEW WELL DEEPEN '/-7 RECONDITION /7 DESTRUCTION /-7 <br /> F <br /> PUMP INSTALLATION / PUMP REPAIR / / r PUMP REpLAC �IT EM /7 <br /> �` <br /> .Other <br /> r ; <br /> DISTANCE TO NEAREST: SEPTIC TANK p SEWER,LINES PIT PRIVY � <br /> SEWAGE DISPOSAL FIELD . CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELLPUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF' WELL' CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. ,of Well Excavation rj rr <br /> Domestic/private Drilled Dia. of Well Casing r <br /> Domestic/public Driven'__ Gauge,:.ofyCasing <br /> Irrigation Gravel Pack Depth of Grout Seal = <br /> Cathodic Protection Rotary Type of Grout k <br /> Other <br /> Diep Deal � �_ Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: "~ <br /> Contractor' - <br /> Type <br /> ontractorType of Pump <br /> P H.P. <br /> PUMP REPLACEMENT:., _• / / State. Work Done..; <br /> PUMP .REPAIR: /7 State Work Done . <br /> ES-TRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree 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 completian,_of, myy,work on a new well, I will furnish the ,San Joaquin Local, Health District <br /> WELL DRILLERS REPORT of the well and notify them before Puttingthe- 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 TOG UTING AND A N INSPECTION. <br /> SIGNED TITLE � <br /> (DRAW PLOT PLAN ON REVERSE SI <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I f <br /> APPLICATION ACCEPTED BY DATE Ar <br /> ADDITIONAL. COMMENTS: - <br /> PHASE I OUT INSPECTION, PHASE I F NAL INSPECTION? <br /> INSPECTION BY ro. DATE i 5 171 INSPECTION. BY DATE l <br /> E H 1426 Rev. 1-74 <br />