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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F094OFFIGE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> i. Telephone: (209) 466-6781 <br /> j2a APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7s= d <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <br /> i (Complete In Triplicate) <br /> Application is hereby wade to the Sam Joaquin Local, Health Districtfor 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 Distridt. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name x <br /> Phone 2171 <br /> I Address <br /> city S Q Wit, .. <br /> Contractor's Name . ¢ � License # _77fo (2 Phone <br /> )/2z <br /> f <br /> 5 <br /> TYPE OF WORK (Check): NEW WELL '/? DEEPEN I-7 RECONDITION /'7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / j PUMP REPAIR l PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 411 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL0 PUBLIC DOMESTIC WELL �I <br /> INTENDED USE t. � TYPE, OFti.W .— I _ ^ _ CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private _. Drilled-.�.-----�•�• - Dias .of-of <br /> Domestic/public" _ .,Driven <br /> Gau a-of Casin r f <br /> Irri -tion ~' ti' - .F - <br /> g Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> —Disposal _� OtherOther Information <br /> _Geophysical <br /> � � . Surface Seal Installed By: =i <br /> PUMP INSTALLATION. <br /> • Contractor <br /> . Type of <br /> PUMP REPLACEMENT:y / IT State01 <br /> ' W rk Done "` <br /> PUMP REPAIR: <br /> ES4RUCTION OF 'WELL Well Diameter <br /> Describe Material and Procedure APProxfma a Depth <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local. Health District <br /> and the State of Califor'riia pextaining`to arLLregulat.irig�well`construction. Within FIFTEEN DAYS <br /> after complgtion. of myiwork.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 GROUT G AND FI INSPECTION. <br /> SIGNED TITLE _(DRAW PLOT PLAN ON REVERSE SIDE <br /> at <br /> PHASE I i <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY /I DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS I FINAL INSPECTION . <br /> INSPECTION BY DATE <br /> INSPECTION BY ` <br /> DATE .5 <br /> E H 1426 Rev. 1-74 <br />