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FOL OFFICE USE: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i 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 Date Issued <br /> ( In <br /> Application is hereby made to the San Joaquin Local Triplicate) <br /> Lo alHealth 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 /> .TOB ADDRESS/LOCATION C_ _ _4'. CENSUS TRACT <br /> Owner's Name � <br /> Phone � , Yo cl <br /> Address '� <br /> `2 �� � '� � City 4� <br /> Contractor's Name et " —"� <br /> L.yt License #/ Phone j ^(' <br /> TYPE OF WORK (Check) ; NEW WELL /7 DEEPEN '/ / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR / PUMP REPLACEMENT /7 <br /> Other f:7 <br /> L <br /> DISTANCE TQ NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PTT <br /> OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Domestic/private <br /> Industrial Cable Tool Dia. of Well Excavation 1� <br /> Drilled Dia, of Well Casing {p� <br /> Domestic/public Driven Gluge of Casing E <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal _ .. Other <br /> Geophysical. Other Information <br /> Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor ; <br /> Type of Pump <br /> _ H.P. \ <br /> PUMP REPLACEMENT: Ll State Work Done <br /> PUMP .REPAIR; <br /> .p'C/� State Work Done f«�` <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 <br /> after completion of lay work on a new well, I will f DAYS <br /> WELL DRILLERS REPORT of the well and notify them beforesPutting athe wellninouse.cal HeThehaboveriet a <br /> information is true to the best of my knowledge and belief. <br /> D A FINALINSPE ION. I WILL CALL FOR A GROUT INSPECTIOri <br /> PRIOR TO GRO LNG <br /> SIGNED <br /> TITL�,,,�121 <br /> PLAN iN ZZTI S <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> AP�PLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE <br /> INSPECTION BY <br /> PHASE ii_09" INSPB ON PHASE II FINAL, INSPECTI N <br /> DATE INSPECTION BY <br /> DATE <br /> 7-777r— <br /> E H 1426 Rev. 1-74 <br /> V76 2K <br />