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SAN JOAQUIN LOCACHEALTH DISTRICT <br /> M' OFFICE USE: 1601 E. Hazelton Ave.., Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP.PERMCT Permit No. 411 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby :Wade 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 - A/6 &V CENSUS TRACT <br /> Owner Q s Name -��� ��'� A t0 - - -- -- Phone g �f0 <br /> Address S 4 City LW lAJLa"J <br /> Contractor's Name �� ,� License ,J%00 Phone <br /> TYPE OF WORK (Check): NEW WELL '/ DEEPEN •/� RECONDITION /_7 DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT f7 <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 TYPE1OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Gable 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: ,� ,Contrac,tor; , _ <br /> Type of Pump, H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP !REPAIR: State Work Done <br /> ,DES;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. FOR A GROUT INSPECTION <br /> PRIOR TO GRO TING AND A FIME INSPECTION. <br /> SIGNED TITLE <br /> {DRAW PLOT PLAN ON REVERSE SIDIOZ2�� <br /> OR ARTMENT JJSE ONLY <br /> PHASE IKM / <br /> APPLICATION ACCE �}LI N O T� DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IAA oINSPECTIO <br /> INSPECTION BY DATE INSPECTION BYr/ DATE ' <br /> E H 1426 Rev. 1-74 1-74 2M <br />