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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL OFFICE USE: 1 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 ' <br /> Application is hereby made to the San <br /> (complete <br /> Triplicate)In <br /> 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 egulations of the San 'Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> I <br /> Owner's Name Phone <br /> �r a � <br /> Address (f <br /> City �y <br /> Contractor's Name � License ���fjoOJ hone YVV� 5/ /,� <br /> I <br /> _ t <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION j—/ DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR-./—/ PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ` <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELLPUBLIC 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 I <br /> Irrigation. Gravel. Pack Depth of Grout Seal {� <br /> Cathodic Protection Rotary Type 'of Grout <br /> Disposal Other Other Information t <br /> Geophysical_ Surface Seal Installed BY: j <br /> PUMP INSTALLATION: ContractoraZA�/ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT:/72 - -e�� <br /> State Work Done <br /> PUMP .REPAIR: n <br /> / / 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 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 />'RIOR TO .0 UTING FINAL INSP CTION. <br /> SIGNED . <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> kPPLICATION ACCEPTED BY DATE 45�2-,P--77 <br /> ADDITIONAL COMMENTS: <br /> PHAS I GROUT INSPECTION P E I /FINAL INSPECTT <br /> INSPECTION BY DATE INSPECTION BY/11,& DATE ' <br /> E H 1426 Rev. 1-74 177 2M <br />