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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOIA OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephoner (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Data Issued 17, <br /> (Complete In Triplicate) <br /> Application is Wereby 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 H�elth`District, <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name - ' Phone,2_ <br /> Address o c} c�•c�� ' -a- City ~ <br /> Contractor's Name License <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN /7 RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR /—/ PUMP REPLACEMENT <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANK qV $EWER INES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICAT ONS \. <br /> Industrial Cable Tool Dia. of Well Excavation <br /> I-- Domestic/private I- Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing �' <br /> Irrigation Gravel Pack Depth of Grout Seal �, v <br /> Cathodic Protection ._ Rotary Type of Grout <br /> Disposal Other Other Information <br />—Geophysical y� <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor C <br /> Type of Pump H. t, <br /> PUMP REPLACEMENT; / / State Work Done ��\\ <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter fry- 2 T^ T Approximate Depths <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health strict <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 TOG 0 PING AND A FINAL INSPECTION. <br /> SIGNED ,. TITLE z_ <br /> DRAW PLOT PLAN ON REVERSE SIDE) "o "• <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY /V c DATE' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPUTION PHASE II FINAL S CT aN <br /> INSPECTION BY - Z DATE INSPECTION BY DAT IE <br /> I�� <br /> E H 1426 Rev. 1-74 11771 <br />