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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> RNA ICE USE: 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 I YEARFROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) ���^ �! �Lr 2 <br /> Appliceition is hereby made to rhe San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is grade 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 CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> I Address - <br /> City <br /> Contractor's Name A A7 <br /> icensdldddce # Phoney 7/d,3/ <br /> _ _ <br /> 0% <br /> _ ..�. :.: . q- <br /> TYPE QF WORK (Check): NEW WELL/ DEEPEN -/- RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR /7 PUMP REPLACEMkNT %f G <br /> Other /% — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> E 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 i Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing ,3 <br /> Irrigation _ /� Gravel Pack Depth of Grout Seal <br /> Cathodic Protection �_ Rotary Type of Grout <br /> Disposal , Other Other Information �. <br /> Geophysical Surface Seal Installed BX: W <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done' <br /> PUMP''REPAIR: /? State Work Done <br /> ES;TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 Sass 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 9GItOUTING AND F AL INS P CTION <br /> SIGNED ITLE <br /> W OT PLAN ON REV SE SIDE <br /> PHASE I DEPARTMENT R US ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II IN PE ON P SEI FINAL INSPECTION <br /> INSPECTION BY AA J DATE INSPECTION BY AIINDATEy <br /> 1 'E H 1426 Rev. .1-74 <br /> 1-74 7M <br />