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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> t FOR -:OFFICE USE: ' 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone; (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2- <br /> 1. P <br /> . <br /> THIS. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued x-77 <br /> Application ism , (Complete In Triplicate) <br /> A <br /> PP 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 Joaqujn <br /> County Ordinance ro. 1862 and the Rules and Regulations of the San Joaquin Local Health.District.dd ! <br /> JOB AD S�S/LOCAT�,O �44?el _ lest%g/Clp._� � ��)� ENSUS TRACToZ -z j�'/ <br /> �Ja/m' <br /> rqfliPhon <br /> r 1 <br /> e <br /> Address <br /> _ City ., <br />` Contractor's Name % {� License It �1 phone r� , <br /> _f/ d � <br /> _ _ a <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_/ RECONDITION /_/ DESTRUCTION ! <br /> PUMP INSTALLATION /? <br /> / / PUMP REPAIR � PUMP REPLACEMENT /_7 •, <br /> Other i/_7 A ; <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES PIT PRIVY -. <br /> r <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER L.S <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED iJSE TYPE OF WELL CONSTRUCTION SPECIFICATIONS N <br /> Industrial - I Cable Tool Dia. of Well Ex avat' <br /> on <br /> Domestic C i <br /> /private R 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 � f <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Itistalled By: <br /> PUMP INSTALLATION: Contractor ' .7;7 j;J <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: <br /> / / State Work Done _ <br /> PUMP .REPAIR: <br /> Site Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure � "- <br /> I � <br /> I hereby agree to comply with All laws and regulations of the San Joaquin Local Health iatric( <br /> and the State of California pertaining to or regulating we11 •'construction. Within FIFTEEN DAYS <br /> after completion of my work onla new well, I will furnish the San Joaquin Local Health District a ' <br /> WELL DRILLERS REPORT of the Weil 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 GROU. G AND A`FI L INS ECTI N. <br /> SIGNED <br /> TITLE <br /> . (DRAW PLOT PLAN ON REVERSE SIDE) <br /> .. <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE 71 <br /> PHASE II GROUT INSPECTION HASE II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74. 2,,: r <br />