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SAN JOAQ'UIN LOCAL HEALTH DISTRICT <br /> FOR"FICE USE: y 160] E. Hazelton Ave. , Stockton, Calif. <br /> - Telephone: (209) 466-6781 <br /> -` APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z,U- 4/p/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM—DATE—ISSUED,- " -Date Issued z -F- <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 s and Regulat ns of the*San Jo quin Local Health District. <br /> JOB ADDRESS/LOCATI , �/ �, / /((/, CENSUS TRACT <br /> Owner°s Name Phone ). "Eel <br /> Address City <br /> Contractor's Name � _...•_....__ _ License I Phoned <br /> TYPE OF WORK (Check): NEW WELL /0j'DEEPEN '/% RECONDITION /7 DESTRUCTION /f f <br /> PUMP INSTALLATION / UMP REPAIR / / PUMP REPLACEMENT r <br /> Other <br /> 'DISTANCE TO NEAREST: SEPTIC TANK , SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT /.2d OTHER �. <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS t' <br /> t' <br /> Industrial moble Tool Dia. of Well Excavation la I <br /> __L�omestic/private Drilled Dia. of Well Casing AV <br /> Domestic/public Driven Gauge of Casing • • <br /> Irrigation Gravel Pack Depth of Grout Seal �Q <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 Sig H.P. <br /> PUMP REPLACEMENT: /-7 State Work Done <br /> PUMP :REPAIR: {" /7 -State Work Done.. <br /> as <br /> ES-TRUCTION OF WELL: Well Diameter <br /> ' - , , •_ 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 FORA GROUT INSPECTION <br /> PRIOR TO GRRUTING AND A FINAL I PECTION. <br /> SIGNED �. /�' TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE)FOR DEPARTMENT USE ONLY <br /> PHASE I - <br /> APPLICATION ACCEPTED BY DATE 7 -,JO.7�1 ; <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III"FINAL INSPECTIO , <br /> INSPECTION BY DATE L-0' :•'•'-� ' INSPECTION BY DATE a <br /> } JE H 1426 }. Rev. 1Y-74 <br />