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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. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued L-i22 2� <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 2 elL.0 CENSUS TRACT _ <br /> Owner's Name . Phone 12J0-�.ot/' <br /> Address a2 City <br /> Contractor's Name � d � ' License a�0Phone <br /> TYPE OF WORK (Check): NEW WELL L7 DEEPEN/7 RECONDITION /7 DESTRUCTION /=T <br /> PUMP INSTALLATION PUMP REPAIR I^7 PUMP REPLACEMENT I <br /> Other /7 <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 (� <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 /> .e.— <br /> + <br /> PUMP INSTALLATION: ContractorH.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: %/ State Work Done <br /> PUMP :REPAIR: <br /> /7 State Work Done <br /> RES•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 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 FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING PNA A FINAL INSPECTION, <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE I INAL SPECTION <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY DATE INSPECTION BYIf� <br /> ti <br /> 1-74 2M <br /> ,:E H 1426 Rev. 1-74 <br />