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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 17- 20 P <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. and the Jules and Re ulations of the San Joaquin Local Health District. <br /> � <br /> JOB ADDRESS/LOCATION! CENSUS TRACT <br /> Owner's Name C Phone 1�? 3 / — <br /> Address <br /> City <br /> Contractor's Name License If hone <br /> � j . <br /> TYPE OF WORK (Check) : NEW WELL /% DEEPEN /_% RECONDITION / / DESTRUCTION /_ i <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER V. <br /> INTENDED <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> 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 RotaryType of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> 14 >4 A& <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT & State Work Don , y <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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTJING AND A FINA INSPEION, <br /> SIGNED (� TITLE �Gy <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ' <br /> APPLICATION ACCEPTED BY DATE A? -7 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS ^ I/FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 7 <br /> E H 1426 Rev. 1-74 1177 - 2M <br />