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SAN JOAQUIN LOCAL HEALTH DISTRICT p� <br /> OFFICE USE; ' 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �� <br /> I THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /S <br /> 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 work2,, described. This application is made .in compliance with San Joaquin <br /> County Or.dinance No, the Rules and Regulati s of the San Joaquin Local Health District. <br /> 30B ADDRESS/LOCATiOCENSUS TRACT /9f=02©-07 <br /> owner's Name �- 41.� Phone <br /> k ti L � <br /> Address ��� City ' <br /> Contractor's Name �d License Phone <br /> TYPE OF .WORK (Check):. NEW WEUI I DEEPEN/ / RECONDITION /? DESTRUCTION /7 ` ! <br /> PUMP INSTALLATION X PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> . SEWAGE AISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER _ <br /> h i <br /> :PROPERTY -LINE .- ,PRIVATE_DOME ST:IrC WELL- ,..P-UBI,IG IaQMES-T-IG-.y,FELL--. <br /> INTENDED USE = TYPE-•OF WELL `' s CONSTRUCTION SPECIFICATIONS <br /> Industrial J -- - <br /> i %..#"��'! " Ca1o'le-Tool ' Dia. -of' We11 ' eavation' <br /> Domestic/private 1 Drilled Dia, of Well Casing <br /> Domestic/public. �` Driven Gauge of Casing <br /> Irrigation :1 Gravel Pack Depth of Grout Seal )� <br /> Cathodic Protection Rotary Type of Grout <br /> d , <br /> Disposal Other Other InformationI . <br /> Geophysical <br /> Surface Seal Installed By: , <br /> S <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 1 <br /> PUMP REPLACEMENT: I ; <br /> / / State Work Done f P <br /> } � a <br /> PUMP .REPAIR: State Work Done <br /> DES•TRUCTION -OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all lams 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 FOR A GROUT INSPECTION <br /> PRIOR TO GRO TING MD <br /> 4ZLFINAL INSPECTION. <br /> SIGNED TITLE } <br /> ` DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY - DATE 2 7;7 <br /> ADDITIONAL COMMENTS: I <br /> PHASE II GROUT INSPECTION PHASE bjWFINAk INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E.H 1426 Rev. 1-74 <br /> 1177 _ " 2M <br />