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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL OFFI E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -z <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application islhereby 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 L e, � CENSUS TRACT <br /> Owner's Name Phone �• /S <br /> Address City <br /> Contractor's Name . License �Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN%/ RECONDITION /_/ DESTRUCTION /- <br /> PUMP INSTALLATION / PUMP REPAIR/ / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAJL FIELD Z!Q- f CESSPOOL/SF�EPAGE PIT OTHER <br /> PROPERTY LINPRIVATE DOMESTIC WELL d PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation zd <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal I <br /> Cathodic Protection )_ Rotary Type of Grout � J P <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: Ale czc k <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 <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 a new well, I will furnish the San Joaquin Local Health District a <br /> WELL' DRILLERS REPORT of a well and notify them before putting thewellin use. The above <br /> information is true t the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTI PE ON. <br /> SIGNED TITLE � <br /> DRAW POT PLAN ON RE FRSE SIDE) i <br /> FOR DEPARTMENT USE ONLY <br /> PHASEf r' <br /> APPLICATION ACCEPTED BY DATE <br /> ................ <br /> ADDITIONAL COMMENTS: <br /> GROUT INSPECTIIO-N-�9 P I /FINAL INSPE TION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />