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r n r <br /> ' SAN JOAQU IN LOCAL'HEALTH'-DI STRICT <br /> } FOS(,OFFICE USE. 1601 E. Hazelton Ave. ,`,S tockton, Calif. <br /> t <br /> Telephone '(209, 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR 'ROM~DATE :"ISSUED' ' -,Date' Issued <br /> i } (Complete in Triplicate) <br /> # Application is hereby made to the San Joaquin Local Health -Diptritt fore.,aHp.ermit:_to construct <br /> and/or install the work herein described. This 1 application made. in`:-comp'liance..with San Joaquin <br /> County Ordinance No.' 1862 and the Rules and Regulations,of the,-Sah, Joaquin Local Health,District. <br /> JOB ADDRESS/LOCATION-: t r., , : CENSUS: TRACT <br /> # <br /> Owner°s Name Phone <br /> Address ' �' F d �r. . Cit <br /> Y <br /> Contractor'a Name : License # z! -Phone k3r -9s 2 o.. <br /> TYPE OF WORK (Check): NEW WELL 17 DEEPEN /? RECONDITION /.7f DESTRUCTION /7 - <br /> PUMP INSTALLATION/ / PUMP REPAIR ./ / PUMP REPLACEMENT %r_ <br /> Other <br /> DISTANCE TO NEAREST:. SEPTIC TANK SEWER LINES PIT PRIVY `k) <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE 'PIT OTHER N) <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL CID <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 t Gravel Pack Depth of Grout Seal <br /> Cathodic Protection .1 Rotary Type of Grout <br /> Disposal. Other Other Information <br /> Geophysical f Surface Spa I Installed By.: <br /> PUMP INSTALLATION: Contractor . ,. . <br /> Type of Pump H.P. <br /> ru <br /> PUMP REPLACEMENT: L/ State Work Done <br /> PUMP :REPA R � " % j State Work Done <br /> k <br /> P&S.'TRUCTION OF WELL: Well Diameter � Approximate Depth <br /> ' .4. <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 theta before putting- the- well in.use.. The above <br /> information is true to the,best.of myknowledge and belief. . I WILL' CALL FOR'A 'GROUT INSPECTION <br /> 4 PRIOR TO .GROUTING AND A FINAL INSPECTION, <br /> SIGNED TITLE <br /> (DRAW,,PLOT PLAN ON REVERSE SIDE <br /> FOR' DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY /!;: DATE 3 �' <br /> ADDITIONAL COMMENTS: <br /> PHASE IT OROUT INSPECTION PHASE II14EINAL.INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E R 1426 Rev. 1-74 1-74 2M <br />