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y SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOR OFFICE USE: ' 1601 E. Hazelton Ave. , ,Stockton, Calif. z <br /> Telephone: (209) 466-6781 v <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 0 7 <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 CENSUS TRACT + <br /> i <br /> Owner's Name 1 Phone <br /> Address City - (-i' <br /> Contractor's Name �� - License � �Ga? ; Phone <br /> ff <br /> t <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/—/ RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> 4 <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 /> 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 /> PUMP INSTALLATION: Contractor ��11_Y f4,;g� <br /> 'Type of Pump H.P. - <br /> PUMP REPLACEMENT:° State Work Don <br /> "-,r-a <br /> PUMP .REPAIR:_ c,__ ,/_/_ State._Wo.rk -Done,_..,.._ <br /> DES�TRUCTION-OF­WELD:- -Well-Diamerte ` Ap`proximate Depth <br /> ,.,., <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 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 OUTING FIN INSPECTION. <br /> SIGNED K TITLE _ <br /> zz (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 3 <br /> APPLICATION ACCEPTED BY DATE 3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA i I/FINAL INSPECTION ' <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 y � i/�77 - 2M <br />