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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOh OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z-7-(2,6110 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,2, <br /> (Complete In Triplicate) <br /> Application is hereby made to the Sao; 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. ].862 a the Rules and Regulations of the San Joaquin Local Health District. <br /> 376-3 ur- d ro, t&-k e d2� <br /> JOB ADDRESS/LOCATION t CENSUS TRACT ' <br /> Owner's Name Phone � - <br /> Address City &=L:ea�-- - <br /> Contractor's Name License # �z�C2 Phone T <br /> TYPE OF WORK (Check): NEW WELL/-7 DEEPEN J7 RECONDITION T DESTRUCTION /T <br /> PUMP INSTALLATION PUMP REPAIR-/-7—PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ,J <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER � <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL f ,s <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS V" <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 Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / J State Work Done �- - _ •. . ._ <br /> ,�]ES•'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 TQagOUTING AND A INAL INSPECTION <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPAR17UMT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ' <br /> ADDITIONAL COMMENTS: — <br /> PHASE II GROUT INSPECTION PHASE I F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br /> ' - ---- ---- x/75 24 <br />