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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOAINFICEUSE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> I Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. !l7,t0 <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> I . <br /> f JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name VA <br /> RAPhone <br />� o <br /> Address <br /> City -�,+t OAI _ <br /> Contractor's Name 4 - _ License # Phone 8 <br /> TYPE OF WORK (Check)-.- -NEW-WE-L-L-/7 DEEPEN/_?—.RECONDITION-/7w --DESTRU �--_ <br /> CTION <br /> PUMP INSTALLATION / / PUMP REPAIR /_7 PUMP REPLACEMENT <br /> Other l/ / ''r <br /> DISTANCE TO NEAREST: SEPTICiTANK SEWER LINES :' PIT PRIVY <br /> r SEWAGE DISPOSAL FIELD �;CCSSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL � I <br /> INTENDED USE TYPE OF WELL t+ CONSTRUCTION SPECIFICATIONS U <br /> Industrial Cable Tool ;''Dia. of Well Excavation <br /> Domestic/private i Drilled IIDia. of Well Casing <br /> Domestic/public Driven ` Gauge of Casing <br /> :4_ Irrigation f Gravel Pack Depth of Grout'Seal . <br /> Cathodic Protection r Rotary <br /> *{ <br /> Disposal i Other :,Type of Grout <br /> Other Information;. F. 1 <br /> —Geophysical. Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT; State Work Dane <br /> PUMP-'.REPA R:t-= /—/T -State Work Done f j <br /> ES; RUCTION OF WELL: Well Diameter i 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 i <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 WILLCALL�F7'A GROUT INSPECTION <br /> PRIOR TO GROU G AND A F MAL CALL <br /> SIGNED <br /> f TITLE <br /> � . (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I a <br /> APPLICATION ACCEPTED BY DATE - <br /> ADDITIONAL COMMENTS: v ; <br /> PHASE II GROUT INSPECTION HA I N INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY ATE <br /> 1 E H 1426 • Rev. 1-74 <br /> 1-7A fv r <br />