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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF_ OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 !, <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued }j <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fora 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 - CENSUS TRACT <br /> Owner's Name / `� 43 <br /> Phone <br /> Address City <br /> Contractor's Name �r�" /7 License <br /> TYPE OF WORK (Check) : NEW WELL /% DEEPEN /% RECONDITION /_/ DESTRUCTION `/_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> O <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY � I <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER _ <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL _ PUBLIC 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 OIL <br /> IrrigationGravel Pack Depth of Grout Seal 0 <br /> 16 f <br /> Cathodic Protection V Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. . <br /> PUMP REPLACEMENT: rrg <br /> State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> 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 <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 GROUTING AND A FI AL INSPECTION. <br /> SIGNED TITLE <br /> C'V <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: `^ <br /> PHASE, II GR UT INS CTION PHASE III/ INAL INSPECTION,, <br /> INSPECTION BY DATE —�� TNSPFCTION BX DATE � <br /> E H 1426 Rev. - 1-74 <br />