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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOP OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466--6781 y <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) <br /> Application is hereby made to the San Joaquin Local Health District ,for a permit to .construc.t <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 r _ CENSUS TRACT <br /> Owner's Name ` Phone <br /> Address ` . ' <br /> L: city ,L i�u.�,�� -- - <br /> Contractor's Name A.- License Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPENAL /_/ RECONDITION / / DESTRUCTION /_7 G <br /> PUMP INSTLATION. / / PUMP REPAIR / / 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�� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation r <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel-Pack „'Depth of Grout Seal` <br /> Cathodzc Protection- ` Rotary =Type of .Grout¢ . <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ti <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: 7)TState Work Donet�F•C,__ yu C . -j <br /> 4 PUMP .REPAIR / / State Work Done ' �N <br /> DESTRUCTION OF WELL: Well Diameter Approximate-.Depth <br /> Q 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 'cod's`txuction. 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 welkin u-se..*, The above <br /> inf ormation� is true to the best of my knowledge and belief. I WILI: CALL FO A-GROUT INSPECTION <br />: PRIOR TO CRO. ING ANDA INA INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SI E) <br /> i <br /> ., FOR DEPARTMENT USE ONLY <br /> PHASE I g <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION s PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE _ , INSPECTION BY DATE _ <br /> .�� E H 1426 Rev. . 1-74 6/77.. - <br />