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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE 1601 E. Hazelton Ade. , Stockton, Calif. <br /> Telephone {209)' 466�6T81 Permit No.1 ? I <br /> APPLICATION FOR WELL CONSTRUCTION-OR PUMP PERMIT <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED' <br /> Date issued <br /> (Complete In Trip ::date) it <br /> `Application is hereby made to the San Joaqu.Th:Ls allicati nth District <br /> made-in -co pliancetwithnSanuJoaquin <br /> and/or install the work herein described. Th PP <br /> Count 'Ordinance No. 1862"'and °the Rules' and Regulations i�f the. San Joaquin L�cHealth °District. <br /> CENSUS TRACT <br />` JOB ADDRESS/LOCATION <br /> Phone <br /> Owner's Name , <br /> City <br /> Address 0 <br /> I incense Phone <br /> Contractor`s Name .r <br /> 4 WORK Check} : UCTION <br /> NEW WELL '/ I DEEPEN/ / RECONDITION I I DESEpACEMEN /� <br /> TYPE OF ( ._ D <br /> PUMP` INSTALLATION / I PUMP REPAIR I I : PUMP R <br /> Other / I <br /> SEWER: LINES _ PIT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC TANK, OTHER <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE .PIT <br /> s PROPERTY:LINE = PRIVA'T'E DOMESTIC WELL PUB <br /> DOMESTIC WELL <br /> INTENDED USE ' TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ' Cable :Tool Dia. - of Well Excavation <br /> Industrial Dia, of ;Well Casing <br /> Domestic/private Drilled <br /> Domestic/public <br /> Driven Gauge of Casing <br /> Irrigation Gravel Pack . Depth of. Grout Seal <br /> T' e' of .Grout <br /> Cathodic Protection Rotary Other Information <br /> Disposal _ Other _ <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> pUMP 'REPLACEMENT: I / State Work Done <br /> PUMP ,REPAIR: / / State Work Done <br /> l r � <br /> DESTRUCTION OF.WELL: Well Diameter I r Approximate De th d <br /> Describe Mat rial and rocedure <br /> I hereby agree. to comply wi all laws an regulati sof the San Joaquin Lacal Health District <br /> and the State of California pertaining to °� willlfurngshethec5ant3oaquin•Local Health pistWithin FIFTEEN Dict <br /> after completion of my work on a new well, <br /> F notify them before putting the well. in..use. The above <br /> WELL DRILLERS REPORT--of •the well and. <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION ION <br /> PRIOR TO GROUTING AND A F N INSPECTION. TITLE <br /> SIGNED <br /> SE S <br /> DRAW PI, T PLAN ON REVE1tIDE) <br /> FOR DEPARTMENT USE ONLY <br /> G <br /> PHASE I DATE -� <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> PHASE Il GROUT INSPECTION INSPECTION BYDATE <br /> INSPECTION BY DATE /J <br /> f G 3/76 2M <br /> I v iLla D—Y 1-71L <br />