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SAN JOAQUIN LOCAL .HEALTH. DISTRICT ti <br /> PLO <br /> OFFICE USE:/ 1601 E. Hazelton Ave. Stockton Calif., a c <br /> 7F � 1 <br /> ,.�: Telephone: (209) 466-6781 � . � � � -� - <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PIRMIT Parmit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> --L <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 /> r /' �r Qr' /W(g <br /> .TOB ADDRESS/LOCATION e � � CENSUS TRACT <br /> Owner's Name. ' Phoned --,��, S <br /> Address - ' a� City <br /> Contractor's Name ,� License #,Phone /7 <br /> TYPE OF WORK (Check) : - NEW WELL ' DEEPEN '/—/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / " PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 1_60 SEWER LINES PIT PRIVY O <br /> SEWAGE DISPOS FIELD CESSPOOL/SEEPAGE PIT Z,5a a ## OTHER <br /> PROPERTY LINEYO PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable-Tool' - Dia. of Well Excavation4 <br /> Domestic/private Drilled Dia. of Well Casing _ <br /> Domestic/public Driven Gauge of Casing z. <br /> Irrigation Gravel Pack Depth of Grout Seal LS <br /> Cathodic Protection o< Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical / Surface-Seal`4Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump l� ��j~ ► / : -H.F. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /7 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 of well and notify them before putting the..well in use. The above <br /> information i tru& t he best of my kimwledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTI 'INAL INS FACT W <br /> SIGNED ��'"Zr+� TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I -. �_ _ _ ., Z <br /> �.. <br /> APPLICATION ACCEPTED BY R.-, DATE <br /> ADDITIONAL COMMENTS: <br /> 44 <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSP N <br /> INSPECTION BY DATE INSPECTION BY - -q-7 DAT <br /> 1r1 7: _ 2M <br /> t E H 1426 Rev. 1-74 - �r <br />