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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 , �_ /� d <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit�No.5 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> t - 2 <br /> (Complete In Triplicate) <br /> Application is ereby 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. 1$ a Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/t * f <br /> G CENSUS TRACT <br /> Owner's Name 42 Phone <br /> Address _ `� City <br /> Contractor's Name �� i/!� License hone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL"ItIc DEEPEN / / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION X7 PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ,e 0- PIT PRIVY <br /> SEWAGE DISP SAL_ELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -�YRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL_/_____1,3:_ <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 Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal G� <br /> Cathodic Protection Rotary Type of Grout ` <br /> Disposal Other Other Information <br /> Geophysical. Surface Seal Installed By: s' (A <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump Mike AFFH.P. <br /> PUMP REPLACEMENT <br /> / / State Work Done <br />"PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION 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 knowled e and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTIO <br /> SIGNED /0 1F1TrPTV <br /> Ka <br /> P N RE OkSE SIDE) ,. <br /> FOR, DFOARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE -21 17 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIZ FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY / ,° DATE <br /> E H 1426 Rev. 1-74 376 2M <br />