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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: V 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 <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 /3,6 I e S A4 6 p CENSUS TRACT <br /> Owner's Name E Ig 4 4A J T 04 L- Phone �3Q" 2'Me'7 <br /> Address ��A r» city <br /> Contractor's Name T. o.�a�cSo�J License #-2,1961v Phone .Q& QpZ <br /> a-r�rear�o <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN /7 RECONDITION /-7 DESTRUCTION f7 --- <br /> 0 MP INST LATION /-7 PUMP REPAIR PUMP REPLACEMENT /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 /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,.REPAIR: State Work Done ,--� <br /> PES•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 CALL FORjA IGROUT INSPECTION <br /> PRIOR TOG UTI G MP4 FANAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDETZ- <br /> FOk_DEgAATMVT USE ONLY <br /> PHASE Ir.. <br /> APPLICATION ACCEPTED BY DATE t <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE UFINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ., DATES . `s <br /> s E H 1426 Rev. 1-74 1-74 2M <br />