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SAN JOAQUIN LOCAL HEALTH DISTRICT 2, / ( <br /> FOE OFFICE 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 Air(Complete In Triplicate) � " ,- <br /> Application is hereby made to the San Joaquin Local Health District for a ppe&it 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 02 602 to / 1�aj r, i7 CENSUS TRACT <br /> Owner's Name CS 7-A,eInj Phone <br /> Address 7 .2,4 City /,24 .)r-s rD <br /> Contract--r'sLicense <br /> Contractor's Name I. 10 � J� Wm -� License # N2,2Z6b6QPhone z2. <br /> TYPE OF WORK (Check) : NEW WELL/_7 DEEPEN / / RECONDITION /_7 DESTRUCTION / <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT fT <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 �J <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 6� <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: C <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 GROUTING AND A FINAL INS ECTION. <br /> SIGNED TITLE <br /> DRAW POT PLAN ON REVERSE SIDE) „ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE = � <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE-III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ,5' 5e_' <br /> E H 1426 Rev. 1-74 <br /> 3/764 <br />