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/V SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP"PERMIT Permit No. 7V_Z�V- .r <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 .2 and the Rules and RegiLlations of the San Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATIONCENSUS TRACT <br /> Owner's Name Phone fl <br /> 9 �� <br /> Address � - + City <br /> Contractor's Name(.,,-" -- '� ""� `'` <br /> License �K � .:�, Phone � � •- � <br /> TYPE OF WORK (Check) : NEW WELL /_7 DEEPEN /`% 'RECONDITION'/-7 DESTRUCTION /7 <br /> PUMA' INSTALLATION / / -PUMP REPAIR / / PUMP REPLACEMENT / <br /> other /_7 ` <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES RIT PRIVY <br /> SEWAGE DISPOSAL FIELD 4 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 , . Drivdn Gauge of Casing <br /> Irrigation , Gravel Pack, Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Group <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> 11.P. `. <br /> PUMP REPLACEMENT: State Work Don.4�� <br /> 'PUMP-M. PAIR--- - /77 State Work Done <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <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 GROUTING AND 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 1— — <br /> ADDITIONAL COMMENTS: _ <br /> PHASE II JT INSPECTION PM9021I NAL INSPECTION <br /> INSPECTION BY U DATE INSPECTION k2U DATE <br /> 4 .. <br /> E H 1426 Rev. 1-74 1=74 2M <br />