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. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOA,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> : . Telephone: (209) 466-6781 i <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) i <br /> Application is hereby made to the San Joaquin Local Health Disttict_•iar 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 CENSUS TRACT j <br /> Owner's Nam a Phone Y.-)- <br /> Address .-)Address City <br /> Contractor's Name License v�_ 4 / Phone <br /> � s <br /> i <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /-7 RECONDITION /7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR 1—/ PUMP REPLACEMENT f <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 1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private drilled Dia. of Well Casing g <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal �Q <br /> Cathodic Protection r---Ifotary 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 /> l <br /> PUMP REPLACEMENT: i-1 State Work Done <br /> PUMP ,.REPAIR: /7 State Work Done <br /> ES-TRUCTION 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 r <br /> WELL DRILLERS REPORT of the well and notify them before putting. the..weli 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 1'0 GROUTING AND A FINAL INSPECTION. <br /> SIGNED A4iTITLE <br /> (DRAW PLOT PLAN ON REVERSE S <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: . <br /> PHASE GROUT INSPE ON PHASE III gINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ,k:Z <br /> E H 1426 Rev. 1-74 1-74 9M <br />