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F . <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> s FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. — S/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> , ( (Complete In Triplicate) <br /> Applicationfis 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. 1662 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION LowdCENSUS TRACT <br /> Owner's Name <br /> Phone , <br /> Address o�0 ' <br /> Ar- <br /> City ' <br /> Contractor's Named <br /> License # J �2VPhone <br /> TYPE OF-WORK (Check)i ' NEW WELL / z "DEEP1/��ONDITION /?` DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR /? PUMP REPLACEMENT /? <br /> Other / . . . <br /> DISTANCE TO NEAREST: SEPTIC 'TANK60 . SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD QQ'' <br /> PROPERTY LINE -- PRICESSPOOL/SEEPAGE PIT OTHER <br /> VATE DOMESTIC WELL PUB �1 <br /> INTENDED USE TYPE OF WELL LIC RiAESTTC WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavation 1j <br /> Domestic/private � j <br /> Domestic/public t DrilledDriven Dia. of Well Casing Gauge of Casing y <br /> _ Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal P Other <br /> .`.� � Other Information <br /> ZA Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: �Co`fntractor <br /> to J �j� � Aet,*pl i <br /> Type..of -Pump H.P. i <br /> PUMP REPLACEMENT. =/�/ - Stati'work Dane° <br /> PUMP :REPAIR: /_7 State Work Doner <br /> DESTRUCTION OF WELL: Well Diameter .� <br /> Describe Material;and Procedure Approximate Depth <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, JC_wilL furnish the San Joaquijn Local. liia'lth District a <br /> WELL DRILLERS REPORT of the well and notify them befor6 putting..the..well': in.use.; ..The above <br /> information is true to the-best. of my knowledke =.a id l eiief. .IWILL_CALL„ FOR,,,A -GR6t7T INSPECTION <br /> PRIOR'TO GROUTING AND A FINAL INSPECTION.; <br /> SIGNED <br /> TITLE,, <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I ` FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE - - -26 <br /> PHASE II GROUT INSPECTIONPHAS II . F AL INSPECT <br /> ON <br /> INSPECTION BY DATE R INSPECTION BY DATE <br /> E H-1426 Rev. 174 <br />