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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF'fi 0 ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: . (209) 466-6751 <br /> APPLICATION FOR WELL CONSTRUCTION OR PULP PERMIT Permit No. :j21_*J <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 <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 ap/o ZZ1a1W111 CENSUS TRACT <br /> Owner's Name � ,� S S� �l �[� !.t 1a 1 Phone �� 1 <br /> Address <br /> Contractor°s Name //rpt IV/ � License Phone�'b <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN /7 RECONDITION /- DESTRUCTION f7 <br /> PUMP INSTALLATIONPUMP REPAIR/� PUMP REPLACEMENT <br /> Other El <br /> DISTANCE TO NEAREST: SEPTIC TANK Z,4SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL, CONSTRUCTION SPECIFICATIONS <br /> IndustrialCable Tool Dia. of WeII Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 11:7— <br /> Irrigation <br /> 1Irrigation .'� Gravel Pack Depth of Grout Seal _ <br /> Cathodic Protection Rotary Type of Grout !Z �` <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type:.:of Pump. -- H.P. /. 5 <br /> PUMP REPLACEMENT: . /_7 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 cpmply 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 /> rafter 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 GRQUTIIJP .AND A PINAL INSPECTION. <br /> SIGNED TITLE ,, <br /> (DRAW- PLOT PLAN ON REVERSE SIDE <br /> FOR' ;DtPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE3 ,� V <br /> ADDITIONAL COMMENTS <br /> PHASE II GROUT INSPECTION PHAS FINAL INSPECT 0 <br /> INSPECTION BYDATE /5' INSPECTION BY DATEX74 <br /> 6 E A 1426 Rev. 1-94 '2M <br />