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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE SE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> —_Telephone: (209) 466-6781 Issued <br /> Permit No. <br /> APPLICATION FOR WELL. CONSTRUCTION OR PUMP PERMIT <br /> T <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date <br /> (Complete In Triplicate) <br />'! <br /> o construct <br /> Application is hereby made to the San ed. This <br /> capplication istrict fo <br /> made inrco pliancea permit twith San Joaquin <br /> and/or install the work 'herein described. Th pp <br /> County Ordinance No. 1862 and the Rules and Regulations of the. Sa . Joaquin Local Health District. <br /> CENSUS TRACT � <br /> JOB ADDRESS/LOCATION �- <br /> Phone <br /> Owner's Name t <br /> ` .. A o fo,3 city <br /> Address <br /> License �� Phone �-"" <br /> x6ontractor's Name a� <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN //� RECONDITION / DESTRUCTION j�T <br /> PUMP INSTALLATION / PUMP REPAIR /,fit/ PUMP REPLACEMENT 1-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY \ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER. <br /> PUBLIC DOSTIC. WELL <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELLCONSTRUCTION SPECIFICATIONS 0 <br /> INTENDED USE TYPE OF WELL <br /> Industrial Cable Tool Dia. of Well Excavation C <br /> Drilled Dia. of Well Casing <br /> Domestic/private <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel pack Depth of Grout Seal <br /> Type of Grout <br /> Cathodic Protection Rotary her Information <br /> Disposal Other <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor �r H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: m� j } <br /> State Work Done �9' Zr <br /> t Approximate Depth <br /> DESTRUCTION OF WELL: Well. Diameter <br /> Describe Material and Procedure <br /> lth <br /> rict <br /> I hereby agree to comply, with all laws odoregulations ot well construction•-SanLoWithcal HnaFIFTEENtDAYS <br /> f and the State of California pertaining <br /> the San Joaquin Local Health District <br /> after completion of my work on a new well, I will furnish <br /> WELL DRILLERS REPORT of .the well and notify them before putting the .well in use. The above <br /> ILL CALL FOR A GROUT INSPECTION <br /> information is true to the best of my.-knows a and belief. I W <br /> PRIOR TO G OUTING AND A FIN N E IO TITLE �- . <br /> .SIGNE <br /> �DgA PL T' PLAN O VERSE SIVE) <br /> FOR D PARTMENT USE ONLY <br /> PHASE I <br /> DATE 7 <br /> APPLICATION ACCEPTED`BY . <br /> ADDITIONAL COMMENTS': PHASE II/FI AL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE <br /> INSPECTION BY DATE <br /> (76 2M <br /> F. V 1426 Rev. 1-74 - <br />