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fSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOArOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> zj APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT `Per it <br /> � � Qo�,� <br /> 2. z — <br /> THIS *PERMIT EXPIRES l YEAR EIS fDat I a <br /> sued ! <br /> ► ; , .: w (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 Re la n e <br /> q n Local Health District. <br /> JOB ADDRESS CENSUS� TRACT <br /> LOCATION/ <br /> Ownei P s Name � j� _._ Phone <br /> Address--- <br /> City <br /> r <br /> Contractors Name License #&�r�PhongM-.28/q <br /> TYPE OF-.WORK (Check).- . NEW WELL /7 DEEPEN/ 7 RECONDITION /7 DESTRUCTION /? <br /> PUMP INSTALLATION /7/'-'PUMP REPAIR /-7 PUMP REPLACEMENT f7 <br /> Other j/ <br /> __�k <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 <br /> i 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 Information <br /> Geophysical 'Surface Seal Installed By _„. <br /> 4 PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. L - <br /> UMP REPLACEMENT: <br /> / / State Work Dane <br /> ,--- <br /> PUMP i.REPAIR: /? State Work Done <br /> E_&TRUCTION OF WELL: Well Diameter Approximate Depth <br /> r 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 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 /> 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 GROUTIN D A FIN SPECTiON. <br /> SIGNED TITLES <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> a FOR DEPARTMENT USE ONLY ,, <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> f ADDITIONAL COMMENTS: - - <br /> PHASE II GROUT INSPECTION PHASE II INAL INSPECTION <br /> INSPECTION By DATE . INSPECTION BY DATE 1f- <br /> 47 <br /> H 1426 . ...,_, <br /> Rev. 1-74 1-74 2M <br />