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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOF�7OFFICE USE; 1601 E. Hazelton .Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> EA� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> E <br /> THIS PERMIT-EXPIRES 1 YEAR FROM DATE ISSUED <br />� 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 Or No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> r. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Dame ~ ! <br /> Phone ' � <br /> Address. <br /> City <br /> Contractor's Name <br /> License # -2yp 747 honeA/CG --p <br /> TYPE OF WORK (Check): NEW WELL DEEPEN ,/?PUMP REPAIR RECONDITION <br /> PUMP INSTALLATION -_ � DESTRUCTION f� <br /> N 1j / -/._ PUMP REPLACEMENT /? <br /> Other, <br /> .DISTANCE TO NEAREST; SEPTIC TANK • <br /> pSEWER LINES PIT, PRIVY <br /> SEWAGE DISPOSAY,,VIELD CESSPOOL/SEEPAGE PIT OTHER' <br /> PROPERTY LINE -- PRIVATE DOMESTIC <br /> INTENDED USE WELL PUBLIC DOMESTIC WELL, `- <br /> ,TYPE OF WELL <br /> IndustriaCONSTRUCTION SPECIFICATIONS <br /> l.,. x.:r..j.4,_ _.:�. Cable Tool -� -- - <br /> Domestic/Private + Drilled Dia.`6f"Well Excavation IV 17— <br /> Domestic/public Driven Dia. of X 117Casing i 4# <br /> Irrigation ` Gauge of Casing : _ Zr- <br /> Gravel Pack Depth of Grout Se 1 � — <br /> _,_.___ Cathodic Protection _ Rotary 4, ....-Type of tGrout , <br /> Disposal r _ Other Other Information <br /> Geophysical -- <br /> Surface :Seal InstallediB : <br /> F 3 . . <br /> PUMP INSTALLATION: ,Contractor <br /> -x <br /> . ,. Type .of Pump <br /> H.P. <br /> P UMP REPLACEMENT: , ` <br /> / / State Woxk_Dower <br /> PUMP '.REPAIR: ' <br /> / State Work Done <br /> OES ~ TION OF WELL: Well Diameter <br /> Zb- Describe Material and Procedure „APProximate Depth <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District , <br /> and the State of California- peitaining 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. iri.use.... .The above <br /> information is true to the best of -1ryy knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO UTING ANDA NAL INSPECTION. <br /> SIGNED ' <br /> TITLE , <br /> s > DRAW PLOT PLAN ON REVERSE SIDE . <br /> PHASE 1', - ,. ' <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS:' DATE , <br /> PHASE II GROUT INSPECTION J PHAS FINAL INSPECTION <br /> INSPECTION BY _ DATE J SPICTION B <br /> E H 1426 Rev. 1-74 <br />