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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone:' } <br /> � -• p (209). 466-6781 � <br /> APPLICATION FOR .WELL CONSTRUCTION OR PUMP PERMIT Permit No.') !(J <br /> THIS PERMIT EXPIRES 1 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 and the Rules and Regulations of the San Joaquin Local Health District. i <br /> JOB ADDRESS/LOCATION 3: °Lt�t4-rt �F_ . � —. CENSUS TRACT <br /> Owner's Name L 44 :k �— Phone <br /> Address '3g(a C� i ,.inn ��a-r� � City A <br /> Contractor's Name t�nl j License Q10gW Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION j / PUMP REPAIR / j PUMP REPLACEMENT /_7 <br /> Other / /. <br /> DISTANCE TO' NEAREST: SEPTIC TANK � SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD - CESSPOOL/SEEPAGE PIT1 OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> IndustrialCable Tool Dia. of Well Excavation ,sl <br /> ^�T Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing J <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surf ace. Seal Installed B { <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> f <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 al <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 niy knowledge and belief, I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR UTING AND A FINAL INSPECTION. <br /> SIGNED 6LA N ATITLE <br /> 1 �(DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> A [CATION ACCEPTED BY DATE . "r' <br /> At,LtTIONAL COMMENTS: <br /> PHASE I GROUT INSPECTION PHASE III/ INAL INSPECTION' <br /> INSPECTION BY � DATE Q..?Zp�: 7� � INSPECTION BY _ DATE <br /> E H 1426 Rev. . 1-74 2M t <br />