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r--- �_ SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FF_0F USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : 6 <br /> r APPLICATION FORONOR1PUMP <br /> WELL CONSTRUCTION PERMIT Permit No. <br /> THIS PERMIT. EXPIRES iRYEAR FROM DATE ISSUED . <br /> t Date Issued <br /> Application is hereby made to the San (Joaquin Local Healthcomplete In Districta -permit <br /> and/or install the work herein described. This application is ,Wade inrcomp <br /> liancetwith nSanuJoaquin <br /> County Ordinance No, 1862 and the Rules and Regulations of the San Joaquin Local Health District, <br /> 1JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> ner's Name " } . - - <br />�. Phone <br /> Address - <br /> f City <br /> ,Contractor's Name r <br /> License # / /Phone�`�� <br /> TYPE OF WORK (Check) : NEW WELLj <br /> DEEPEN/ / RECONDITION / / *ESTRUCTION <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY ' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC <br /> TTHER <br /> NTENDED USE WELL— <br /> TYPE OF WELL Industrial CCONSTRUCTION SPECIFICATIONS <br /> able Tool Dia. of Well Excavation <br /> Domestic/private Drilled _ <br /> Domestic/public Diof Well Casing <br /> ` Driven Gauge of Casing <br /> Irrigation � � Gravel Pack <br /> Depth of Grout Seal <br /> Cathodic Pzo` ectiori {-ROther Rotary Type of Grout <br /> Disposal i c a3 nformation <br /> GGeophysical <br /> eo phy ]Other I <br /> e � ----------- "-' <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> _ H <br /> •" S .P, <br /> PUMP REPLACEMENT: / / tate Work__Done <br /> PUMP .REPAIR: / / State Work Done <br /> 1 <br /> bES-TRUCTION OF WELL: Well Diameter ! <br /> Desc ibe Mater i ad Procedure Approximate Depth <br /> -�-- <br /> /—A __ •. ! rte, _ . <br /> I hereby agree to complyvwith all laws and regulations f the�Sdn Joaquin Local Health Distract, r <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 /> BELL 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. r <br />'RIOR TO GROUTING AND A FINAL .INSPECTION, 8 I WILL CALL FOR A GROUT INSPECTION <br /> 1IGN <br /> TITLE <br /> {DRAW PLOT PLAN ON REVERSE SIDE) <br />'RASE I FOR DEPARTME U$E-ONLY <br /> APPLICATION ACCEPTED BY - ' <br />,DDITIONAL COMMENTS: ' DATE <br /> PHASE II GROUT INSPECTION PHASE IIT FINAL INSPECTION <br /> NSPECTION BY DATE INSPECTION BY <br /> DATE 1[ <br /> 3 J4 <br /> E H 1426 Rev. 1-74 F. . <br /> :,1'7-7 <br />