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J SAN jOAQUIN LOCAL HEALTH-DISTRICT <br /> Y 1601 E. Hazelton Ave. , Stockton, Cali . <br /> FOE OFFICE USE: �� f �,(� . <br /> Telephone: (209) 466-6781 L <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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 /> JOB ADDRESS/LOCATION 9 J03 21J CENSUS TRACT <br /> Owner's Name 1z Phone <br /> o <br /> Address S 'i City �'K - - <br /> Contractor's Name <br /> M: License # ILL Phone Rips i <br /> aj <br /> TYPE OF WORK (Check) : NEW WELL '/ / DEEPEN/ / RECONDITION �/ DESTRUCTION /-7 I <br /> PUMP INSTAL TION / / PUMP REPAIR /S� PUMP REPLACEMENT /� <br /> / / a <br /> Other ' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ?IT PRIVY I <br /> SWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC, WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS y\; <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/ <br /> private rivate <br /> Drilled Dia. of Well Casing p <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 i Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: �/ / State Work Done <br /> • PUMP 'REPAIR:" il/ / State Work Done <br /> A roxite Depth - <br /> b DESTRUCTION OF WELL Well Diameter PP maF <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Diatxictf <br /> and the State of California pertaining to or regulating well'constructfon. Within FIFTEEN DAYS <br /> after completion of myi�work on a new well, I will furnish the San Joaquin Local Health District a <br /> k WELL DRILLERS REPORT of the well and notify them before putting the .well in use. The above <br /> information is true to'Ithe-best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO OUTING AND A FINAL INSPECTION. <br /> SIGNED IM TITLE <br /> iM D 6d i PLAN ON RE P S IRE <br /> iqR DEPARTMENT USE ONLY <br /> PHASE I LX}UCzµL! riDATE <br /> APPLICATION ACCEP BY <br /> ADDITIONAL LOMANTS: IF <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY iM DATE INSPECTION BY DATE 7(0 <br /> F , V76 2M" <br /> ;. E H 1426 Rev. 1-74 <br />