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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORIOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 7- 35/fa <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .50- 6 7j <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 /(,S �p� <br /> s­ <br /> 1044A44-ec::1. CENSUS TRACT <br /> Owners NameCSP Phone <br /> Address City <br /> Contractor's Name License A-916aJ15 Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_% RECONDITION /_/ DESTRUCTION /`7 <br /> PUMP INSTALLATION PUMP REPAIR /% PUMP REPLACEMENT /7 <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 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 <br /> Irrigation Gravel Pack Depth of Grout Seal k <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor +.: -_ <br /> Type of Pump H.F. <br /> PUMP REPLACEMENT; / / State Work Done .V <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 DAIS <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 true to the best of my knowledge' and belief. I WILL C L FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY Z <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE I ROUT INSPECTION P E /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ,�(( <br /> {/.J <br /> E H 1426 Rev. 1-74 x/17 ' 2M <br />