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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> io—K-OFFICE USE: 1661 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone:" ' (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ,ISSUED <br /> 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 a*7 <br /> � CENSUS TRACT <br /> Owner's Name ' <br /> Phone �, Z <br /> Address <br /> ON City , j <br /> Contractor's Named 3 y <br /> License # Phon E 1 I q�- j <br /> TYPE,OF WORK (Check): NEW WELL/ DEEPEN /? RECONDITION /? DESTRUCTION f7 <br /> PUMP INSTALLATION / Mp REPAIR /� PUMPREPLACE /- r <br /> Other MENT -- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVAT DOMESTIC WELL" PUBLIC DOMESTIC <br /> INTENDED USE TYPE WELL <br /> Industrial OF WELL CONSTRUCTION SPECIFICATIONS <br /> fE <br /> _ able Tool Dia. of Well Excavatio <br /> . n n <br /> stic/private Drilled Diao£ Well Geeing [�I <br /> Domestic/public _ Driven Gauge of Casing <br /> l � <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Pr-otection Rotary Type of Grout <br />' Dispose] , Other• Other Information ' ' V�? <br />_Geophysical Surface Seal Installed 'B <br /> y. <br /> PUMP INSTALLATION: l <br /> Contractor. <br /> Type of Pump H.P. <br /> PUMA'' REPLACEMENT: • / / State Work Done <br /> PUMP-:REPAIR`- -ter. --- <br /> tate`Work Dona _ _t. .••...,�y�- .:-,... _ _„�,� _..•�_ _ <br /> DE&TRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> } Describe Material and Procedure ~----- <br /> I hereby agree .to comply with -'all. Iaws 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. <br />'RIOR TO GROU NG A INSPE I WILL CALL FOR A GROUT INSPECTION <br /> SIGNED " F TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br />'VASE I _ <br /> FOR DEPARTMENT USE ONLY <br /> O'PLICATION ACCEPTEDBY <br /> IDDITIONAL COMMENTS.; DATE . J`�- 9 <br /> PHASE II QROUT INSPECTI N <br /> INSPECTIONBY DATE f PHASE I FINAL INSPECTION <br /> INSPECTION BY DATE z� <br /> E H 1426 <br />.,.,� Rev. 1-74 <br />