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f , . J : SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> , Application ie hereby made tdlthe San Joaquin Local Health District for a permit to construct <br /> ' and/or install the work herein described. This application is grade in compliance with San Joaquin <br /> ' County Ordinance No. 1862 and�ijthe Rules and Regulations of the San Joaquin Local. Health District. <br /> .ry � <br /> JOE ADDRESS/LOCATION /2K G• ©/ _ o _ CENSUS TRACT <br /> Owner's Name Phone <br /> Address , �� p • City.' ' <br /> Contractor's Name ease #/22_,P­/J Phone 10 -&;w V <br /> TYPE OF WORK {Check): NEW-WELIL /? DEEPEN j RECONDITION %T DESTRUCTION /? <br /> PUMP INSTALLATION -/ PUMP REPAIR PUMP REPLACEMENT f_7 <br /> Other %. / <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 k! Cable Tool Dia. of Well Excavation <br /> Ddmestic/private Drilled _ Dia. of Well Casing <br /> Domestic/public,.. Driven Gauge of Casing? --- Q\ <br /> Irrigation., :I. Gravel Pack Depth of Grout Seal p <br /> Cathodic Protection it Rotary Type of Grout <br /> Disposal 4 11 Other Other 'Information <br /> ,-Geophysical. L ;i Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump .. A.P. <br /> -PUMP REPLACEMENT: %/ Sate Work Done <br /> PUMP `.REPAIR: State Work Don <br /> IDES1RUCTION OF WELL:. Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> kI hereby agree to comply withlj'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 qty 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•be't of- my. knowledge and 'belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FIN �IIINSPECTI ,N. - -[ SIGNED TITLE <br /> �I (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> { PHASE I <br /> r APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS= ilh <br /> PHASE II GROUT INSPECTION P E III FINAL INSPESTION <br /> ' INSPECTION BY DATE INSPECTION BY DATE � �� <br /> + CC <br /> E H 1426 Rev. 1-74 - <br />