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SAN JOAQUIN LOCAL HEALTH <br /> FOES OFFICE USE: DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> ! <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 /> 1 and/or install the work herein described. This application is made in :compliance with San Joaquin <br /> : County Ordinance Na. 1$62 and the Rules and Regulations of the San :Joaquin .Local Health District. <br /> 30B ADDRESS/LOCATION _,04 ` sAtext o �7 . � <br /> CENSUS TRACT <br /> I .-Owner"s Name <br /> Phone <br /> 'Address' Address D <br /> Af 4l city ' . <br /> .Contractor's Na - <br /> License # /19-^7%-J Phone 2G <br /> TYPE OF WORK (Check): NEW WELL -/ " DEEPEN-/7 f RECONDITION / DESTRUCTION /^j <br /> PUMP INSTALLATION T/ PUMP REPAIR/_7 PUMP REPLACEMENT I f <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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS p <br /> Indust - CONSTRUCTION Cable Tool Dia. of Well Excavation <br /> - � Domestic/private , Drilled Dia, of Well .Casing � <br /> Domestic/public,`a'- 4 Driven <br /> Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br />. Cathodic Protection -. Rotary Type of Grout \'\, <br /> Disposal <br /> Other . Other Information <br /> Geophysical _�,'• <br /> Surface "Seal.Installed 'B <br /> f PUMP INSTALLATION: <br /> Contractor <br /> t . _... .. Type 'of Pump <br /> PUMP • ' LX/. State Work Done. <br /> PUMP '.itEPAIR: State Work Done <br /> sDES•TRUCTION -OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with all laws and regulations of---t-he-San Joaquin Local Health District <br /> sand the,,State of California pertaining to or regulating we11 "construction.. Within FIFTEEN .DAYS <br /> cafter".compietion of my work on a new well, I will furnish the San Joaquin '1-oval Health District a <br /> VELL'DRILLERS REPORT of the well and notify them before -putting.-the..well. i-n.use.. The above <br /> ;information .is true to- the-best of my owle d belief, I WILL CALL FOR A -GROUT INSPECTION <br /> PRIOR TO GRQUTING AND A FINAL IN <br /> GT / <br /> :SIGNED _Sp, poj TITLE <br /> D W PLOT PLAN ON IWERSE SIDE) � <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> ?APPLICATION ACCEPTED BY <br /> :ADDITIONAL COMMENTS: $ . / <br /> PHASE II GROUT INS ION .r - <br /> "INSPECTION BY CTPHASE :III INAL INSPECTION <br /> - �- DATE INSPECTION BY DATE -7 <br /> il <br /> E H 1426 Rev. 1-74 !.int. <br />