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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 /> Z7 1 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S-lollol'o <br /> THIS PERMIT EXPIRES I 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/LOCATIONCENSUS TRACT <br /> Owner's Name Phone <br /> Address - City <br /> Contractor's Name ef4& License Phone a <br /> TYPE OF WORK (Check): NEW WELL/_7 DEEPEN '/7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION /7 PUMP REPAIR /-7 PUMP REPLACEMENT ) <br /> Other / / <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 G� <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 : <br /> 1 \ <br /> PUMP INSTALLATION: Contractor ( <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,.REPAIR: /7 State Work Done <br /> j2ES®RUCTION 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 C,41, FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AD "INAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE^ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GRO NSPECTION PHASBjIVtrINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - - S <br /> E H 1426 Rev. 1-74 1-74 2M <br />