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SAN JOAQUIN LOCAL HEALTR4'DSTRICT <br /> FG`A 0__MCE USE: 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 6 7> <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 Rule and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 7 fk-> CENSUS TRACT <br /> Owner's Name _ �l ' `P � Phone <br /> Address City <br /> Contractor's Name License Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL0 DEEPEN '/—/ RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /7 <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 SPECIFICATI NS �. <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing C, <br /> Domestic/public Driven Gauge of Casing �j <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection � Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical. Surf ace Seal Installed B <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 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 u e. The above <br /> information is true to the best of my owledge and belief. I WIL L FOR OUT INSPECTION <br /> PRIOR TO GRVJING AND A FINA INSPECT10a, <br /> SIGNED TITLE <br /> (DRAW. PLOT WLAN ON REVERSE Si <br /> FOR DPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> DATE �1-= <br /> ADDITIONAL COMMENTS; <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE y 7 <br /> E H 1426 Rev. 1-74 3/76 2M <br />