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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. '?l <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. . .Date Issued f�_l I <br /> (Complete In Triplicate) Ji <br /> Application is hereby made totthe 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 andlthe Rules and Regulations of the San Joaquin Local Health District. <br /> .4,ta. <br /> JOB ADDRESS/LOCATIONvtTCENSUS TRACT ' <br /> }� s <br /> Owner's Name r Phone <br /> Address LCity <br /> Contractor's Name License # Phone �� 6 <br /> TYPE OF WORK (Check) : NEW WELL/? DEEPEN /� RECONDITION DESTRUCTION Y <br /> PUMP INSTALLATION / / PUMP REPAIR7f�PUMP REPLACEMENT f f <br /> Other j_7 <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 <br /> INTENDED-USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing �E <br /> Domestic/public 1 Driven Gauge of Casing <br /> Irrigation t Gravel Pack Depth of Grout Seal k <br /> Cathodic Protection t Rotary Type of Grout j <br /> Disposal .1 Other Other Information <br /> Geophysical r Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> TypeType of Pump H.P. k <br /> PUMP REPLACEMENT / / Sate Work Done i <br /> PUMP ,'REPAIR: / State Work Done AW <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure t <br /> ff <br /> I hereby agree to comply withlall laws and regulations of the San Joaquin Local Health District � <br /> and the State of California pertaining to or regulating well'construction. Within FIFTEEN DAXS.: <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <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 R2UTING AND A FINAL INSPECTION. , <br /> SIGNED Y2j TITLE <br /> D W PLAN''ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> �, <br /> APPLICATION ACCEPTED BY �• <br /> - � LATE / ,�-,Z. & <br /> ADDITIONAL CON MENTS: R <br /> PRASE II GROUT INSPECTION P E I FI AL INSPECTIOW. <br /> INSPECTION BY DATE INSPECTION BY DATE 74 <br /> E S 1426 Rev. 174 3/76 �t b <br />