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FOE."OFFIGE USE: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 I <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Triplicate} Date Issued <br /> Application is hereby made to the San Joaquin Local Health Distract for permit and/or install the work her described. This aPpxfcation is made in compliance ECounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquinp t to construct <br /> P with Sen Joaquin <br /> r JOB ADDRESSAA Local Health District. <br /> Owner's Name <br /> Address �� Phone <br /> Contractor's Name City- <br /> License <br /> .ZZZj&hone <br /> TYPE OF WORK (Check): NEW WELL ` DEEPEN/I RECONDITION DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR _7 PUMP REpLACEMEN- ]. ..�J <br /> Other <br /> DISTANCE TO NEAREST: <br /> SEPTIC TANK�p- SSR LINES � <br /> SEWAGE DISPOS IELD — PIT PRIVY <br /> P�tOPERTY LINE CESSPOOL/SEEPAGE PIT L ,6-OTHER <br /> INTENDED USERIVA DOTE MESTIC WELL-S-0-4-PUBLIC DOMESTIC WELL "^- <br /> TYPE 11(31? WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool <br /> Domestic/private Dia. of Well <br /> /public ng <br /> Driven Excavation tT <br /> Domestic Drilled Dia. o€ Well Casing <br /> �- <br /> s <br /> Irrigation Gauge of Casing <br /> Gravel Pack Depth of Grout Seal <br /> Cathodic Protection <br /> Rotary Type of Grout a <br /> Disposal - Other <br />—Geophysical —..�-- Other Information " -- <br /> Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor i <br /> Type of Pump y <br /> • H.P. <br /> PUMP REPLACEMENT: ' / State Work Done <br />°' 'REPAIR: State Work Done <br /> EESITRUCTION OF WELL: Well Diameter <br /> Describe Mater al and Procedure 1 Approximate Depth <br /> hereby agree to comply with all Iaws and regulations of the San Joaquin Local Health Distri <br />,nd the State of California pertaining to or regulating well 'construction. ct <br /> fter completion of my work on a new well, I will furnish the San Joaquin LoWithin cal FIFTEENlth DAYS a <br /> ELL DRILLERS REPORT of the well and notify them before putting-the .well. in.use.,.. <br /> nformation is true to the-best -of- my. knowledge an belief. I WILL The above <br /> tIOR TO GROUTING AND A FINAL INSPECTIO CALL FOR A GROUT INSPECTION <br /> IGNED <br /> ( POTPE 2 <br /> REVERSE SIDE <br /> LASE I DE TMENT USE ONLY <br />?PLICATION ACCEPTED BY <br />)DITIONAL COMMENTS: DATE , 7 /7A <br /> GROUT INSPECTION P SE <br /> DATE FINAL INSPECTION <br /> ISPECTION $Y - - g INSPECTION BY <br /> DATE <br /> E H 1426 Rev. 1-74.. — <br />