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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR QFiFICE"JSE: 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 4,,*4Z ,{/' CENSUS TRACT <br /> Owner's Name ` u ) a Phone <br /> Address 3, a - NU P.4 <br /> City <br /> Contractor's Name License # Phone7�1 � <br /> i <br /> TYPE OF WORK (Check) :. NEW WELL. /`a' DEEPEN/ / RECONDITION / / DESTRUCTION /-7 <br /> PUMP REPAIR <br /> PUMP INSTALLATION e <br /> �/ / /_PUMP REPLACEMENT /? 7� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK za, SEWER LINES/ZZL:t- PIT PRIVY <br /> SEWAGE DISPOSAL FIELDCESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE.O'PRIVATE DOMESTIC WELL/&Y— PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation f Z' <br /> t-, Domestic/private Drilled Dia. of Well Casing g'"'� <br /> Domestic/public Driven Gauge of -Casing f 0 <br /> Irrigation Gravel Pack Depth of Grout Seal ' <br /> Cathodic Protection ^ &e- Rotary Type of Grout tom. <br /> Disposal Other Other Information <br /> Geophysical. Surface Seal Installed By: <br /> fi <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 <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 GROUTING AND A FINAL INSPECTION, <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE / - d 7� INSPECTION BY DATE /Z -T <br /> °�%� <br /> E H 1426 Rev. - 1-74 - ,{ <br />