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- R SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> _LOBrOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PtRMIT Permit No. <br /> THIS PERMIT _EXPIRES 1 YEAR FROM DATE ISSUED Date Issued X00--15 <br /> I (Complete In Triplicate) b ' (-- q-0- 7-6 <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 <br /> County Ordinance No.. 1862 and the Rules and Regulations of the San Joaquin Local Health District. E <br /> ` ENSUS TRACT <br /> ;YOBS ADDRESS/LOCATION <br /> Ft j Phone 3 3 54 <br /> -Owner Q s Name <br /> Address <br /> City . <br /> Contractor's Name 10 - 0'-c ar/ __ License #I_�I_ 73 Phone,3C?�'�L� <br /> •J` <br /> TYPE-OF-WORK-.-(Check.-)--:—NEW-WELL-`z/DEEPEN`.-/�T RRCONDITI013 "/� DESTRUCTION f7 j <br /> PUMP INSTALLATION / / PpMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> k DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ' PROPERTY INE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> L <br /> INTENDED USE tTY L E WELL CONSTRUCTION SPECIFICATIONS <br /> l Industrial 1 Cable Tool Dia. of Well Excavation - _j <br /> I Domestic/private I 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 /> • <br /> Contractor - ` f <br /> PUMP INSTALLATION: - <br /> _ �. Type` `Of...Pump H.P. <br /> PUMP REPLACEMENT: / State Work Done <br /> PUMP :REPAIR:' �� ' State Work Done <br /> Approximate Depth <br /> ES;TRUCTION OF WELL: We11 Diameter <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> I 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 /> 1 PRIOR TO GTIN AND NAL INSPECTION. <br /> TITLE <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I 71 <br /> APPLICATION ACCEPTED BY DATE V <br /> ADDITIONAL COMMENTS: ' <br /> PHASE II OUT INSPECTION 4 PHASE I I/FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY P DATE <br /> 1-74 2M <br /> E H 1426 Rev. 1-74 <br />