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,� .q,�...�y--_ _.•_ ate:: <br /> L1 <br /> SAN -JOAQUIN LOCAL HEALTH DISTRICT <br /> EOF CsFFICE USE: id 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 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit `to construct ; I <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 CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> I -- - <br /> Address � <br /> Cit C� <br /> Contractor's Name <br /> License Phone' ' t�' <br /> TYPE OF WORK (Check) : NEW WELL � <br /> / J DEEPEN '/_/ RECONDITION / / DESTRUCTION /_ _ <br /> PUMP INSTALLATION /`f PUMP REPAIR /% ,PUMP REPLACEMEN <br /> Other T_ J / <br />, DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY -- <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPACE 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 We11 Excavation <br /> Domestic <br /> /private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of <br /> CasingGravel:-Back- De th- <br /> - <br /> i <br /> of-Grout--Se1Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br />;t Geophysical Surface Seal Installed B : <br /> 'UMP INSTALLATION: <br /> Contractor <br /> Type of Pump <br /> H.P.At,AO <br /> . <br /> MP REPLACEMENT: State Work Done <br /> {,UMP, PAIR: J State Work Done <br /> 'STRUCTION` OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> d 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 thea 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 kno .. dg and elief I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO G G AND A FINAL INS <br /> SIGNED 3 <br /> TITLE. <br /> (D P OT P ON R ERSE SIDE) <br />'RASE I R DEPARTMENT USE ONLY <br /> 1PPLICATION ACCEPTED BY <br /> ODITIONAL COMMENTS: DATE IZ <br /> PHASE II GROUT INSPECTION <br /> S PECTION BY PHASE III/FINAL INSPECTION <br /> DATE INSPECTION BY DATE f LH 1426 Rev. • 1-74 ii./%7 _ 2M <br />