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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE (?FFIGE USE: , / 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 1/ Telephone: (209) ,466-6781 <br /> APPLICATION FOR'-WELL;.dONSTRUCTION OR PUMP PERMIT Permit No. <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 t <br /> County Ordinance No. 1862 and the Rules and Regulations of the .San Joaquin Local Health District. � <br /> I <br /> JOB ADDRESS/LOCATION r, CENSUS TRACT <br /> t <br /> Owner's Name - f <br /> Address O ! City 1 <br /> Contractor's Name -� <br /> License 3� Phone " 6Z� <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/ i RECONDITION-0 YDESTRUCTION f7 i <br /> PUMP INSTALLATION / -PUMP REPAIR _PUMP REPLACEMENT I? -� <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 ML <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS - <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 /> a Type of Pump H.P.I/ <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP .REPAIR: - State Work Done <br /> DESro <br /> TRUCTION 'OF WELL: Well Diameter A xima_� De h i <br /> Describe Material and Procedure # ' <br /> I hereby agree to comply with all lams and regulations oe�,� .TYi <br /> A Health District <br /> and the State. -of California pert"ng to or regulating well''construction. Within FIFTH= 75 <br /> after comp ion of work. on ;-new- ; I wi -� ____aT--Health Dietrica a <br /> WELL' DRIL RS OR € the w 1 a no y them before putting the.-well in use. The abo'v� , <br /> informat on is t m owledge and belief. I WILL CALL FOR' GROUT IISPECTI1; <br /> PRIOR TO G G A ION. <br /> SIGNED TITLE <br /> D W. PLAN 'ON UffkSE SIDE <br /> { OR F TMENT USE ONLY <br /> PHASE I , , k <br /> 4 DATE ..Z"... <br /> APPLICATION ACCEPTED � L <br /> ADDITIONAL COMMENTS: _ - <br /> PHASE G PECTiDN PHASE NAL. NSPECTION. <br /> INSPECTION BY DATE INSPECTION BY ATE � <br /> F 3, 76 2K <br /> E R 1426 Rev. 1-74 <br />