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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> AP ICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued 3 a 77 <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.,ithe 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 /> .TOB ADDRESS/LOCATION T 81 CENSUS TRACT <br /> Owners Name Phone <br /> r <br /> Address City <br /> Contractor's Name Licensejqqf,0 Phone / <br /> TYPE OF WORK (Check) : NEW WELL/4—r"DEEPEN /7 RECONDITION /? DESTRUCTION /? <br /> r PUMP INSTALLATION /�UMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / - I_-;- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES /0a 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 /> 4,---Domestic:'/private drilled h Dia. of Well Casing v <br /> Domestic/public Driven Gauge of Casing p <br /> IrrigationGravel Pack Depth of Grout Seal <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.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP...REPAIR: . •- r:::. - /_7 State Work Done <br /> ` APDESTRUCTION OF WELL. Well Diameter Proximate Depth <br /> Describe Material and Procedure <br /> 1 <br /> I hereby 'agree to comply with all laws and regulations of the `San Joaquinuin Local Health District <br /> and the Stategof. 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'IREPORT 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 GROUTING4D A FINAL INSPE <br /> SIGNED TITLE <br /> ' <br /> W P : T PLAN 'ON RE VERSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I �} <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: y <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTIO <br /> INSPECTION BY.: C. DATE ,rc I" ;�1 _ INSPECTION BY. DATE <br /> � . 3/76 214 <br /> E H 1426 Rev. 1-74 <br />