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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 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 E�/ <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 s CENSUS TRACT <br /> Owner's Name —7o E Phone <br /> Address 7 RocA..& City ''V"'y'z <br /> Contractor's Name `�' V , X License ��� Phone 70 ���®,3 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION /046� PUMP REPAIR / / PUMP REPLACEMENT <br /> 0 ther <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 />_.>goo"' Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor V�/ "M •.� <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 <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 DAYS <br /> after completion of my work on a 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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROPTINg4AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> {DRAW -PLOT:PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY A <br /> PPE I <br /> APPLICATION ACCEPTED BY DATE _ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA I/ INAL INSPECTIO <br /> INSPECTION BY % DATE INSPECTION BY DATE 16 <br /> 0/77 _ 2M <br /> E H 1426 Rev- 1-74 <br />