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SAN JOAQUTN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: ' a � 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 "� t <br /> 'APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I 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 Joaquin <br /> County Ordinance No. 1862 andrthe Rules and Regulations of the San Joaquin Local Health District. t <br /> JOB ADDRESS/LOCATION 6 Z E �, A N _ _ CENSUS TRACT <br /> Q� t <br /> Owner's Name Phone Zo ' <br /> r # <br /> Address <br /> X191Z City - e c <br /> Contractor's Name License #3M/3 Phone - /7 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN _/ RECONDITION /_/ DESTRUCTION /? <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 G` I <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 t, Gauge of Casing <br /> Irrigation Grave.l�PackVt ' Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Other Other .Information <br /> Disposal , - <br /> GeophysicalSurface Seal Installed B <br /> PUMP INSTALLATION:'y Contractor <br /> Type of Pump H.P. .� <br /> PUMP REPLACEMENT / / State Work Done <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 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 /> E PRIOR TO GROUTIN AN9 A FINAL IUPPECTION. f <br /> SIGNED `ISLE <br /> 7�7DRAW P T' PLAN ON RE FRSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ; y <br /> APPLICATION ACCEPTED BY . + <br /> DATE 7 .. OD' <br /> ADDITIONAL COMMENTS; - <br /> {PHASE-Il GROUT INSPECTION PHASE I-II/FINAL INSPECTION <br /> INSPECTION BY' DATE INSPECTION BY DATE - •-?? <br /> F 3/76 <br /> E H 1426 Rev. 1-74 <br />