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SAN JOAQUIN LOCAL HEALTH DIStICT <br /> FOF "OFFI E 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 ,�a <br /> (Complete In Triplicate) <br /> Application' is hereby made to Ahe 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. <br /> JOB ADDRESS/LOCATIONS ee , CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address 41 'Al 12C <br /> City <br /> k <br /> Contractor's Name 40 License # <br /> phone0a)-7."74 <br /> ., <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPENF/ /; RECONDITION /_/ DESTRUCTION / 7 <br /> PUMP INSTALLATION PUMP REPAIR '/_,/ PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY f <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 4 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ! <br /> Industrial a Cable Tool Dia. of Well Excavation <br /> Domestic/private i Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> (� Irrigation 1 Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 1 Rotary Type of Grout <br /> Disposal 1 Other Other Information ' <br /> Geophysical. + Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump H.P. <br /> PUMP REPLACEMENT: / / State-Work Done <br /> PUMP-WRktiR: State Work Done X 1 <br /> F k <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,.Jo'aquin 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 knowled and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO OUTING AND A FINALSP CT <br /> SIGNED "" `T'ITLE <br /> I DRA h T PLAN O RSE SIDE ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - <br /> APPLICATION ACCEPTED BY �. DATE <br /> ADDITIONAL COMMENTS !1 <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE C� <br /> . r . <br /> 3/76 ZK <br /> E H 1426 Rev. 1-74 =-J <br />