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I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFIC S. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) x+66--6781. % <br /> APPLICATION FOR WELL CONSTRUCTION 'OR PUMP PERMIT Permit No. <br /> 'THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date' Xssued y� -77 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San- Joaquin Focal Health District for a permit to construct i <br /> and/or install the work herein describ This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rulean ulations of the San Joaquin Local. Health District. <br /> jJOB ADDRESLS/LOC4,TION CENSUS TRACT <br /> s <br /> Owner's Name Phone g!3 <br /> 4 � <br /> Address 7 O Cit <br /> Contractor's Name License Phone <br /> i' <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION_/ / DESTRUCTION% 7 <br /> PUMP INSTALLATION/ / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER s <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 /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal i <br /> Cathodic Protection Rotary, Type` of Grout <br /> Disposal Other Other Information 1 <br /> Geophysical ace Seal Installed By: s <br /> PUMP INSTALLATION: Contractor <br /> Typee -of Pump H.P. i <br /> 3 <br /> PUMP REPLACEMENT: /, / State Work Done i <br /> i <br /> PUMP .REPAIR: / / State Work Done �Y <br /> DESTRUCTION OF WELL: Well Diameter 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 FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE �✓' <br /> DRAW PMT PLAN ON RE ERS E S IDE ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I J(1 DATE <br /> APPLICATION ACCEPTED BY, v�� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PII1jKNALjNSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE <br /> E H 1426 Rev. 1-74 _ 3/76 2M <br />