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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFOFFICE 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 S e-Ttj <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, Sani-Jon uinal a lth District. <br /> JOB ADDRESS LOCATION a CENSUS <br /> Owner's Name Phone <br /> Address 1 kus, City . <br /> Contractor's Name 7-:r License hone 41G iW74 <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN /7 RECONDITION /7 DESTRUCTIONL7 <br /> PUMP INSTALLATION L-7PUMP REPAIR --7 PUMP REPLACEMENT LT <br /> Other Lam' <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 /> 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 WA. ' <br /> Type of Pump H.P. y-a <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: 57 State Work Done CL -24 p jL / 196for a . <br /> PES-TRUCTION 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- know1 nd belief. I WILL CALL FOR A GROUT INSP CTION <br /> PRIOR TO GROUTING AND A FI IN OE 0 f <br /> SIGNED,.& TLE <br /> T PLAN ON R SE SIDE <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE f 2- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROM tMPECIONPHASE III FINAL INSPECTIOnN <br /> INSPECTION BYATE INSPECTION BY DATE ' ! <br /> E H 1426 Rev. 1-74 1-74 2M <br />