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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. <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 Jo4quin { <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 2 Z- )`- CENSUS TRACT <br /> Owner's Name a Phone .4_ <br /> Address j City <br /> Contractor's Name [,c� License Phone <br /> TYPE OF WORK (Check) : NEW WELL /L-/ DEEPEN/ / RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION /Z PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK [ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE,56'PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �. <br /> Industrial L. Cable Tool Dia. of Well Excavation <br /> d. 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 ,,, r <br /> Disposal Other Other Information <br /> Geophysical <br /> Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor ce- 7 d <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done - <br /> D,ES,TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all Jaws 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 />'RIOR TO GROUTING ANP A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY " DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTPN PHASE III/FINAL _INSPECTION <br /> INSPECTION BY - _ DATE Yl &Z7 INSPECTION BY / DATE <br /> E H 1426 Rev. 1-74 2M Al <br />