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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0—R7OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 176- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2,,7 76 <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 CENSUS TRACT <br /> Owner's Name 4Phone <br /> Address 0 tCity 1 <br /> Contractor's Name License # Phone -cc- oco <br /> TYPE OF WORK (Check): NEW WELL -/-7 DEEPEN '/-7 RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION/ / PUMP REPAIRPUMP REPLACEMENT /- <br /> Other /% i <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 �l\ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation p <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: , I / State Work Done <br /> F <br /> PUMP .REPAIR: State Work Done <br /> UES•TRUCTION OF WELL: Well Diameter Approximate <br /> 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-bestof my-knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TOINC AND A FIN INSPECTION. <br /> SIGNED TITLE " <br /> DRAW PLOT PLAN ON REVERSE SI <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7-14 ",74 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II -FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE . <br /> E H 1426 Rev. 1-74 4/75 2m <br />