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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOPi'rOFFiCE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR P0P PERMIT Permit No. <br /> I <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. 18622/and the Rules and Regulations of the San Joaquin Local Health District.�P <br /> JOB ADDRESS/LOCATION / 0 �� g� -�--t� CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address U City <br /> Contractor's Name �� � License #Ae&19 Phone K±Z Lo6 <br /> TYPE OF WORK (Check) : NEW WELL -L-7 DEEPEN '/-7 RECONDITION /-7 DESTRUCTION <br /> PUMP INSTALLATION /? PUMP REPAIR /-7 PUMP REPLACEMENT <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 O <br /> INTENDED_USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> W <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 A <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: j/7 State Work Done `aao, . <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 <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 C44L FOR A GROUT INSPECTION <br /> PRIOR TO G UTING hNA2 FI AL TNS ECTION. <br /> SIGNED TITLE V-167-2 tk <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> - R DEP TMENT USE ONLY __._ <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 3 d p <br /> ADDITIONAL COMMENTS: <br /> PHASE I U INSPECTION PHASE FEN INSPECTION <br /> INSPECTION BY TE INSPECTION BY DATE <br /> a E A 1426 Rev. 1-74 <br /> 1-74 2M <br />