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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephoner (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,V 112 <br /> 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 work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 n tty� Rule a d Regulations of the S�quin Local <br /> c 1 He h District. <br /> �` / ! <br /> JOB ADDRESS/LOCATION � � CENSUS TRACT <br /> Owner's Name ��, Phone <br /> Address City <br /> Contractor's Name /cel License Phone � � <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN—RECONDITION /_/ DESTRUCTION <br /> AL / f <br /> PUMP INSTLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <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 11 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS N <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 r SurC�face Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / 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 Distri <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAY <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <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 INSPECTIO <br /> PRIOR TO GROU ING AND A L INSP CTION. ' <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE -��'' 77 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE j4T&*FINAI,,aNSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 0 <br /> E H 1426 Rev- 1-74 <br /> o,/7 7 2M <br />