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/ SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOF OFFICE USE: (! 1601 E. Hazelton Ave. <br /> Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. X75, <br /> V) THIS 'PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued ` <br /> (Complete In Triplicate) <br /> Application is hereb}i'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 /> t County'Ordinance No, 1862 an' the Rules and Regulations of the San Joaquin ,Local Health District. <br /> : rJ <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address <br /> City �/ G.-�, <br /> Contractor's Name License. F Phone fLe�l7 <br /> TYPE OF WORK (Check) : NEW WELL Q� DEEPEN '/ / RECONDITION /-7 DESTRUCTION fi;�' <br /> PUMP. INSTALLATION PUMP REPAIR `/ -/ PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK �` EWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL--FiELD=W --�,CESSPOOL/SEEPAGE-PIT` OTHER <br /> PROPERTY LINED PRIVATE DO <br /> MESTIC"WELL PUBLIC FDOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION"SPECIFICATIONS <br /> Industrial Cable Too Dia, of Well Excavation <br /> Domestic/private Drilled' Dia of Well Casing <br /> Domestic/public Driven ' <br /> Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout ,Seal <br /> Cathodic Protection >e,' Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal I <br /> nstalledBy <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump '5/- <br /> H.P. <br /> PUMP REPLACEMENT <br /> / / 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 we nd notify them before putting the..well' in use. The above <br /> information is true to the-b wle e and belief. I WILL CALLtFOR A GROUT INSPECTION <br /> PRIOR TO GROUTIN PECTI N f <br /> SIGNED �1•c. � TITLE I <br /> _- <br /> (DRaW PLOT PLAN ON REVERSE SIDE) 4 <br /> FOR DEP4RTMENT USE ONLY <br /> PHASE I �. . <br /> APPLICATION ACCEPTED BY � � -' `�' DATE <br /> ADDITIONAL COMMENTS:9 ey �.� <br /> GROUT INSftCTjO11P PIJAag- ,II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E :H 1426 Rev. 1-74! 1: 1177" - 2M <br />