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L/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ��- 3 6�c,1 <br /> je 233,E <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6 <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/LOCATION CENSUS TRACT <br /> Owner's Name j <br /> Phone <br /> at �� <br /> Address City <br /> Contractor's Name 1pl� License #,PS Q- phone <br /> TYPE OF WORK (Check): NEW WELL DEEPEN/7 RECONDITION /_7 DESTRUCTION /-7 <br /> PUMP INSTALLATION ,a PUMP REPAIR/ pump REP CEMENT <br /> Other <br /> DIST E TO NEAREST: <br /> SEPTIC TANK f5'© , SEWER LINES PIT PRIVY <br /> u ,4/ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ff PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing t,,Lt <br /> Domestic/public Driven Gauge of Casing ._ <br /> Irrigation Gravel Pack Depth of Grout Se '— <br /> Cathodic Protection �L Rotary Type of Grout edeamsg 4t 0,4,v <br /> Disposal Other Other In€ormation <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump (� <br /> H.P. <br /> PUMP REPLACEMENT j/ / State Work Done <br /> PUMP :REPAIR: /7 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <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 CAL14 FOR A GROUT INSPECTION <br /> PRIOR TOG UTING AND FIN INSPECTION. <br /> SIGNED ddg TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE i FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE 5 ....G <br /> ADDITIONAL COMMENTS: 7 <br /> PHASE II GROUT INSPECTION PHASE 1111F INSPECTIO <br /> INSPECTION BY DATE - INSPECTION BY DATE " <br /> E H 1426 Rev. 1-74 L/7K 9M' <br />