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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE pFFICE 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 is hereby made tolthe San Joaquin Local Health District for a permit to construct j <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1$62 and1the Rules and Regulations of the San Joaquin Local Health District. <br />. JOB ADDRESS/LOCATION CENSUS TRACT ` <br /> Owner's Name Phone r <br /> 4 <br /> Address64 i <br /> cit <br /> Contra'cJtor'sName-- License # Phone <br /> TYPE OF WORK (Check) : NEW WEA <br /> r/ / DEEPEN '/ / RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION /� PUMP REPAIR/ / PUMP REPLACEMENT /_7t : Other / / ': . — <br /> -, <br /> DISTANCE TO NEAREST: " SEPTIC TANK, ,2 55 SEWER LINES I AS fPIT PRIVY b v <br /> SEWAGE DISPOSAL FIELD ] CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY; LINEIPRIVATE 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 Drilled; Dia. of Well Casing <br /> Domestic/public- .y,; .F1�k Driven Gauge of Casing <br /> Irrigation -- ' <br />�1C g Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Qther Other Information <br /> Geophysical Surface Seal Installed B ,-,Qdxo4 <br /> PUMP INSTALLATION: Contractor VA11VICIZ.011, Oemll 6 <br /> Type of -Pump { H.P. 71 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: <br /> 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 /> Ind 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 /> BELL DRILLERS REPORT of the well and notify them before putt g 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 />'RIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br />?HASE I <br /> APPLICATION ACCEPTED BY DATE V <br /> ADDITIONAL COMMENTS: <br /> PHASE-II GROUT-INSPECTION PHAS - I/ NALxINSPECTION- <br /> CNSPECTION BY DATE � , INSPECTION BY c DATE <br /> E H 1426 Rev. 1-74 11R .2M �L <br />