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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> PW OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 y �` <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,7 r SS�j <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued - q -7¢ <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 anheuleees an Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATI ��YIJJaa,4, r y f ' <br /> �'K CENSUS TRACT <br /> Owner's Name f �. Phone <br /> Address ( citycH <br /> Contractor's Name 00 License 1h�u�o9, �.�. <br /> one <br /> TYPE OF WORK (Check): NEW WELL /�EEPEN -/7 RECONDITION 17 DE§TRUCTION /7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR /-7-pump RIIILAGEMENT /7 <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> ,;INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Data. of Well Excavation <br /> _Domestic/private Drilled Dia. of Well Casing �A <br /> Domestic/public Driven Gauge of Casing �r <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout - <br /> r <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump3 H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR-. /7 State Work Done <br /> ,SES 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 /> PRIOR TO GRO TING D A LINAL INSPECTION. <br /> SIGNED l TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED 'BY DATE <br /> ADDITIONAL COMMENTS: - <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY . DATE /1- /,, *fie,! INSPECTION BY DATE <br /> k <br /> + E H 1426 Rev. 1-74 1-74 2M <br />