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JOAQUIN LOCAL HEALTH DISTRICT, <br /> FOR.OFFICE USE: 160A., Hazelton Ave. , Stockton, Cal _# <br /> .1 <br /> Telephone: (209)' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -%6�3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 Joaquil <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION g <br /> QQ �V r 6I. CENSUS TRACT ' <br /> Owner's Name Phone <br /> Address City <br /> Contractor°s Name ,` ,r ' License # j Phone <br /> r <br /> TYPE OF WORK (Check) ; NEW WELL / DEEPEN RECONDITION /-7 DESTRUCTION /-7 <br /> ;I PUMP INSTALLATION J / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK + SEWER LINES 4 " PIT PRIVY <br /> SEWAGE DISP SA FIELD �/C OOL/SEEPAGE PIT OTHER <br /> ' PROPERTY LINE - PRIVAT�MESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OE,,WELL CONSTRUCTION SPECIFICATIONS <br /> IgAttstrial Cable Tool Dia, of Well Excavation <br /> omestie/private Drilled Dia. of Well Casing <br /> Domestic/public. Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sealg� �. <br /> Cathodic Protection Rotary Type of Grout <br /> G. <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: � . / J State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> E <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 DAIS <br /> after coEmpletion of my work on a new well, I will furnish the San Joaquin Local Health Distrie't a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information ;�q true to the est of my knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO"GR G D A AL INSPECTION. <br /> SIGNED TITLE l r <br /> (DRAW MOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> F DEPARTMENT USE ONLY <br /> . <br /> APPLICATION ACCEPTED BY DATE 1 2--� 2 a- <br /> ADDITIONAL COMMENTS; <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DAT 7 <br /> E H 1426 Rev. 1-74 1/77 . - 2M <br />