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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR+r OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUtiIP PERMIT Permit No. /-7",!c/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued //7g <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 heandnthesAu�esdandTRegula�ia�sto�nthe SadneJo�qu�.��ocaleHealthSan <br /> District�n <br /> County ordinance No. 1862p � <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> Owner's Name � Phone <br /> City � <br /> Address �- <br /> Contractor's Name License #fG 37 Phone3C �r° <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /7 RECONDITION /7 DESTRUCTION fT <br /> PUMP INSTALLATION jx/ PUMP REPAIR /� PUMP REPLACEMENT f-T <br /> Other / / <br /> DISTANCE TO NEAREST: EPTIC TANK .� SEWER LINES �_ PIT PRIVY <br /> EWAGE DISPOSAL FIELD CESSPOOL/,SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL f UBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial y_ Cable Tool Dia. of Well Excavation " a '? <br /> �. Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing / d <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout -�-`� <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: %/ State Work Done ' <br /> ,PUMP !REPAIR: ,- / / State Work'Done <br /> ,3E&TTRUCTION OF WELL'! Well Diameter T 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 Di"it ict 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 GROXTIFfi AND A42NAL INSECT ION. , <br /> SIGNED TITLE <br /> PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE yy- <br /> APPLICATION ACCEPTED BY - ' <br /> I ADDITIONAL COMMENTS: <br /> PHASE II G SP CT N PHASE IIT/F N INSPECTIO <br /> INSPECTION BY DATE INSPECTION- BY �• DATE <br /> i E R 1426 Rev. 1-74 1-74 2M <br />