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., ► X,,PO <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO . OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6751 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> Q . <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 Sen Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the -San Joaquin Local Health District. <br /> .TOB ADDRESS/LOCATION_ !/ CENSUS TRACT <br /> Owner's Name Phone <br /> Address City , <br /> Contractor's Name License 4Z hone <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN '/-7 RECONDITION f7 DESTRUCTION f7 <br /> PUMP INSTALLATION A7/- PUMP REPAIR/-7 PUMP REPLACEMENT / r <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 C.. <br /> Industrial Cable 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: Contractor <br /> Type of Pump oW H.P. <br /> PUMP REPLACEMENT / State Work Done <br /> PUMP .REPAIR: /-7 State Work Done <br /> DESTRUCTION OF WELL: Well DiameterApproximate Depth All, <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 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 IIj?FjNAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 r' 4/75 2M <br />