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i SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORiOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Cali'.. <br /> Telephone: (209) 466-67'81 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT,,,„_ Permit No. <���5� <br /> # , <br /> ' THIS PERMIT SU <br /> EXPIRES 1 :YEAR�-FROM DATE ISED 'Date Issued <br /> (Complete In Triplicate) :; <br /> Application is hereby made to the San Joaquin Local Health• District. for,a•perai�,t. ta construct <br /> and/or install the work herein described. This application': is ='ade-An compliance,,with San.-Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of. the San:Joaquin Local �eaSth .District. <br /> i' JOB ADDRESS/LOCATION CENSUS TRACT <br /> �. <br /> Owner's Name <br /> Phone <br /> Address <br /> Ci,. ..._. y.. - .... . <br /> ty c �. <br /> Contractor's Name Licence'it"7y Phone4,C (1- G <br /> -- <br /> TYPE OF WORK (Check): NEW WELL '/-7 DEEPEN / RECONDITION /? f <br /> " DESTRUCTION / <br /> PUMP INSTALLATION /� PUMP REPAIR /—/-PUMP REPLACEMEgT 17 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK �CSEWER LINES PIT PRIVY <br /> SEWAGE DISP05AL FIELD CESSPOOL/SEEPAGE PLT. OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL/0_0 PUBLIC DOMESTIC 'WELI: <br /> INTENDED USE TYPE OF .WELL CONSTRUCTION SPECIFICATIONS 0 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casin <br /> g ,. <br /> Domestic/public Driven Gauge of Casing <br /> _ Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection _ Rotary Type of Grout <br /> Disposal Other Other Info <br /> - rmation <br /> Geophysical _. Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: - State Work Done . A"If <br /> PUMP':REPAIR: /7 State Work Done <br /> BSITRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin. Local Health District <br /> and the State of Californi pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> After completion of m ark on a new well, I will furnish. the San Joaquin Local Health District a <br /> WELL DRILLERS REPO of the well and notify them before putting the- well in_use.. The above <br /> information is a to the-best of my-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR SP ON. <br /> SIGNED TITLE r ._ j <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY I <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE (,[ 7 <br /> ADDITIONAL COMMENTS: =- <br /> PHASE II GROUT INSPECTION HA E I FIN INSPECTION . <br /> INSPECTION BY DATE INSPECTION B DATE /B, <br /> 'i E H 1426 Rev. I-74 F <br /> 1-74 2M <br />