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SAN JOA(;JINI-LOCAL HEALTH DISTRICT +_ <br /> FOFirOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7�i� p wry <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued���/0 <br /> (Complete In Triplicate) <br /> Application is hereby made to the Sari 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 i <br /> CENSUS TRACT <br /> Owner's Name - + <br /> Phone �� p 90� <br /> Address " <br /> City <br /> Contractor's Name ` ' <br /> w t. a License .� .._ <br /> TYPE-OF WORK (Check): NEW WELL /!E�''DELPEN •/_7 RECONDITION /? DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR / PUMP REPLACEMENT_ <br /> /� <br /> Other /J E <br /> DISTANCE TO NEAREST: FSEPTIC TANK SEWER LINES PIT PRIVY <br /> ;SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INPROPERTY LINE - PRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL <br /> TENDED USE # TYPE WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial f <br /> a Cable Tool .0 Dia. of Well Excavation <br /> omestic/private Drilled {, Dia. Of Well, Casing so2Z <br /> Domestic/public Driven Gauge of Casing _` <br /> Irrigation = i Gravel Pa& Depth �df,4Grout Seal <br /> Cathodic Protection Rotary -'Type of Grout' . <br /> Disposal Other Other Information 4 " <br /> Geophysical'. l � ,��'"" �--•--- <br /> •° Surface Seal Installed B <br /> PUMP INSTALLATION: ` Contractor <br /> Type of Pump ' H.P. <br /> PUMP REPLACEMENT: /:/ State Work Done . <br /> PUMP 'REPAIR: // State Work Done "'"""` - "'.. 7"`","`' <br /> ES•TRUCTION OF WELL: Well Diameter ;F' <br /> Describe Material and-'Ptocedure Approximate Depth <br /> I hereby agree to comply with all laws and'regulat$ons of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating taell 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 G T 1G .AND A F NAI, INSPECTION. <br /> STGNED , . TITLE <br /> - -(DRAW•PLOT PLAN-ON REVERSE SIDE)' '- "°— <br /> PHASE I " FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE3 O'7 <br /> ADDITIONAL COMMENTS: , <br /> _PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY — - DATE INSPECTION BY -- DATE <br /> E H 1426 Rev. 1-74 <br />