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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> [FLO �:I:C�E:USE: 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone : (209) 466--6781 ' ,ks ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES-1 YEAR FROM DATE ISSUED Date IssuedL <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District- for a permit to constrict R * <br /> and/or install the work herein described. This application is made in .compliance with San Joaquin <br /> County Ordinance Na. 1862 and- the Rules• and. Regulations. of the San Joaquin Local Health .District .i <br /> JOB ADDRESS/LOCATION <br /> gra d a flr. CENSUS TRACT <br /> Owner's Name ' <br /> Phone =S'/ 5117 <br /> Addressa City <br /> Contractor's Name X490" C License # 0165774/phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION /_/ DESTRUGION /- <br /> PUMP INSTALLATION /Z. PUMP REPAIR /,/- PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK hT ' SEWER LINES '_ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD -.�- -*-, CESSPOOL/SEEPAGE PIT"`"`_. `OTHEk• <br /> PROPERTY LINE PRIVATE EST <br /> -DOMESTIC WELL PUBLIC DOMI.C,,WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS \ <br /> *� Industrial i Cable fool Dia. of Well Excavation k, <br /> Domestic/private-,,_,, 1 Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge. of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal ; {- <br /> Cathodic Protection Rotary 7T-e of Grout_ O <br /> Disposal Other <br /> Other Information °= <br /> Geophy`s i caJ <br /> Surface Seal Installed By: n� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pumper fA, roe Z42 <br /> i ..r riA �-C <br /> PUMP REPLACEMENT: State Work , <br /> / / Done <br /> PUMP REPAIR: /7 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approxi teDe ' : <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regula-tions of the 'San Joaquinv:;ocal;, Ith District E <br /> and the State of California pertaining to .or._.regulating vw.ell..4czrL&t -uEtl.on�Wi.th FTEEN DA'YS' � <br /> aftdr .completion of my work on a new well, I will furni-s� the San JoaqunMocal.''H 1thi District a <br /> WELL DRILLERS REPORT of the well and notif <br /> y them before putting the well in use":�The. Mabove. <br /> information is true to the best of my knowledge and belief. I WILL CALL ""R AYGROUT'INSPECTIO <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) n <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY 1 DATE` fa7�7 ) <br /> ADDITIONAL COMMENTS: <br /> PHASE IT GROUT INSPECTION PHAS III/FINAL INSPECTION ' M <br /> INSPECTION BY DATE INSPECTION BY DATE � <br /> I <br /> E H 1426 Rev. • 1-74 <br />