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-Pe <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <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. Z2 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Daae 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/LOCATION ® '�J %rr = CENSUS TRACT <br /> Owner's Name Phone 2?= <br /> `-' ti' . <br /> Address ,ta <br /> City . <br /> Contractor's Name rs License hone <br /> TYPE OF WORK a(Check)s_ NEWWELL Imo., DEEPEN /� - RECONDITION-/-:-7- -DESTRUCTION f7-- <br /> PUMP INSTALLATION / PUMP REPAIR I PUMP REPLACEMENT /7 <br /> -,Other_-%/� <br /> .DISTANCE TO NEAREST: SEPTIC TANK "SEWER LINES, PIT PRIVY <br /> SEWAGE DISPOSAL FIELDCESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS v <br /> Industrial s Cable Tool ` Dia. of Well Excavation �� \ <br /> Domestic/privateDrilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation p <br /> g Gravel Pack, !1 a Depth of Grout Seal --a- ' <br /> Cathodic Protection Rotary - `` Type of Grout : <br /> Disposal ' Other ti:Other Information <br /> -Geophysical <br /> Surface Seal installed 'By �i'1. (�ii►���r <br /> PUMP INSTALLATION: Contractor'° <br /> Type of Pump <br /> H.PW <br /> TM <br /> PUMP /REPLACEMENT: .,, / State Work Done, <br /> PUMP .REPAIR: � <br /> /7 State Work Done} � <br /> DESTRUCTION OF WELL Well Diameter Approximate .Depth <br /> Describe Material an4 rocedure_ <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" o or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my-work on anew 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 GR0 NG AND, IN ECT N. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> D <br /> EP4RTMENT USE ONLY <br /> PHASE i <br /> APPLICATION ACCEP DATE <br /> ADDITIONALCOMMENTS: .; . <br /> PHASE II GROUT INSPECTION PHASI F AL INSPECTIO <br /> INSPECTION BY -' DATE INSPECTION BY A DATE ,R <br /> H .H 1426 Rev. 1-74` /,7c ou j <br />