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f i SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOh OFFICE USE: /"" 1601 E. Hazelton Ave. , Stockton, Calif. <br />! .1; Telephone: (209) 466-6781 <br /> U APPLICATION! ON FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> i <br /> a THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �7 <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 work1herein 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 �! �� "' <br /> r � CENSUS TRACT <br />',Owner's Name I�; Phone - a <br /> Address a Cit <br />, Contractor's Name p License # �pdPhone cf3sll,, <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT Al <br /> Other <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 On <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 /> L� <br />, PUMP INSTALLATION: CFontractor <br /> Type of Pump H.P. <br /> jPUMP REPLACEMENT: State Work Done PC� <br /> II <br />+' PUMP .REPAIR: /f`, / State Work Done - <br /> DES—TRUCTION 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 Fthe 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 AN A FIN IN PECTION. , <br /> SIGNED TITLE <br /> IM� (DRAW PLOT PLAN ON REVERSE SIDE)- <br /> V <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY p DATE <br /> ADDITIONAL COMMENTS: 11. <br /> PHASE II GROUT INSPECTION P I /FINAL INSPECT ON. <br /> INSPECTION BY dj" DATE INSPECTION BY _r DATE' / /79 <br /> E H 1426 Rev. 1-74 , -- <br /> 117.7 2M <br />