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TZ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: ' 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.77 13L <br /> f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is Aereby 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 Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION IIl CENSUS TRACT <br /> Owner's Name Phone <br /> Address City �1 <br /> Contractor's Name License #/1� Phone.34r-33 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / / RECONDITION /_/ DESTRUCTION /_ <br /> PUMP INSTALLATION REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT-PRTVY -'- <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ' PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBY,IC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <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 <br /> Cathodic Protection "Rotary Type of Grout \ � <br /> Disposal ` Other Other Information <br /> Geophysical . Surface Seal Installed By:' <br /> PUMP INSTALLATION: Contractor 'J ' I <br /> Type of Pump, <br /> H.P. <br /> PUMP REPLACEMENT: <br /> / / State Work Done <br /> PUMPREPAIR: / / State,Work Done _ <br /> DES-TRUCTION OF WELL: Well Diameter Y b '. _.Approximate Depth <br /> Describe Mater�ial 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 CALL FOR A GROUT INSPECTION <br /> PRIOR TO OUTING AN FINAL INSPECTION. <br /> SIGNED TITLE f <br /> (DRAW PLOT PLAN ON REVERSE SIDE) , <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY / r^ <br /> ADDITIONAL COMMENTS: <br /> DATE <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE _ , INSPECTION BY DATE <br /> _E H 1426 Rev_ 1-7G X1677 1.W <br />