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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. 26___515�0. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DateX'ssued � 6 <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/(�P�ft�IAl"/ @ I a l CENSUS TRACT 1 <br /> Owner's Name <br /> Phone��a �� -3 , <br /> AddressCity <br /> -- License �� Z Phone 3 <br /> Contractor s Name �� <br /> - i <br /> TYPE OF WORK (Check) : NEW WELL 'o DEEPEN/ / RECONDITION /' DESTRUCTION <br /> PUMP 'INSTALLATION'-F-7 `P�"E' REPAIR / / PUMP REPLACEMENT / 7 <br /> Other <br /> DISTANCE TO NEAREST: SEP.-TIC.-TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD , CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTYAre�INE - .PRIVATE -DOMESTIC WELL - PUBLIC DOMESTIC WELT. �# <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS f� <br /> Industrial 7. Cabl,.e Tool Dia. of Well Excavation //O <br /> Domestic/private 'Drilled Dia. of Well Casing <br /> .,� <br /> Domestic/public Driven Gauge of Casing r <br /> Irrigation Gravel. Pack Depth of Grout Seal �er <br /> Cathodic Protection -Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical "Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor `" <br /> Type of Pump H.P. <br /> , <br /> PUMP REPLACEMENT: / / State Work Done <br /> x• <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 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 <br /> WELL DRILLERS REPORT of the well and notify them before putting the..well in use. The above <br /> information is Arue 'to the--best of my�knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> F PRIOR TO GROU - D' A ' ,N 'INSPECT ON':"- <br /> SIGNED TITLE <br /> RAW­P T.PLAN ON RE�IFRSE SIDE} <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE g <br /> E APPLICATION ACCEPTED BY f <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II/FINAL INSPECTION <br /> f INSPECTION BY T DATE INSPECTION BY ,.....� DATE <br /> ` 3/76 2M <br /> E H 1426 Rev. 1--74 _-_.. .. _. <br />