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`SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOEOFFICEUSE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> �► �(/1� 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 ® .AS/7 l -U -z? to _ CENSUS TRACT <br /> Owner's Name - �� ��� Phone <br /> } l`✓�Y <br /> Address p�2 ,A �/ ,,,� -n �_ City (' <br /> Contractor's Namea L ofo License ��hone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/)�f DEEPEN /_/ RECONDITION /_/ DESTRUCTION /-7 <br /> AL <br /> PUMP INSTLATION REPAIR/ / PUMP REPLACEMENT /7 <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISP SAL 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 " (y <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sealt7 <br /> Cathodic Protection �C Rotary Type of Grout 13'e" y r,i e <br /> Disposal Other Other Information <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 <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 GROUTI AND A FIN ION. <br /> SIGNED TITLE <br /> DRAW�PLXVT PLAN ON REM SIDE f <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY y - DATE ..- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/ INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 3a, 774 <br /> E H 1426 Rev. 1-74 /1-19 . , , a-e O o- 2M <br /> 6 � � � <br />