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SAN JOAQUIN LOCAL'HEALTHDISTRICT - - - -T <br /> I <br /> 1OE.r05FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466'F 6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Cd <br /> THIS PERMIT EXPIRES 1.YEAR FROM DATE ISSUED, Date Issued/- `_ , .7 <br /> 6 - <br /> (Complete In,Triplfcate) <br /> Application is hereby made to the San Joaquin Local n alth District for a permit to construct <br /> and/or install the work herein described. This-applica ion is made in compliance with San Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulationsof the San Joaquin Local Health District. <br /> .TOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name Phone !� <br /> Address 5Z,.in <br /> rp City Q <br /> Contractor's Name - .License - hon <br /> TYPE OF WORK (Check): NEW WELL , EPEN RECONDITION /-7 DESTRUCTION <br /> PUMP• INSTALLATION / P.UMP REPAIR /—/—PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST:. SEPTIC TANK 15 SEWER LINES IM PIT PRIVY <br /> i SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PITT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC 'WELL PUBLIC.DOMESTIC WELL <br /> - `INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> R Industrial <br /> �, Cable Tool '. Dia. of Well Excavation <br /> ` t-Domestic/private Drilled Dia. 1of Well Casing { <br /> I3omestic� rubl3e . a _, Driven Gauge ofY"Casin _ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> f Cathodic Protection RotaryType1�of Grout <br /> Disposal Other Other Informati h <br /> Geophysical Surface Seal Installed B <br /> PUMP-INSTALLATION: - Contractor <br /> Type of Pump • iN H.P. <br /> PUMP REPLACEMENT: L/ State Work Done <br /> k <br /> f <br /> PUMP '.REPAIR: �-7 State Work Done4 <br /> ES-TRUCTZON OFYWELL:, Well Diameter Approximate Depth <br /> ' Describe Material and Procedure iM <br /> II <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> a and the State of California pertaining to or regulat.ing ,iwell 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 before1putting 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 /> PRIOR TO GB2WNGAND A FINAL INS E <br /> SIGNED TITLE , <br /> 1 <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR EPARTMENT ,jUSE ONLY <br /> PHASE I <br /> .: APPLICATION ACCEPTED BY . <br /> DATE Z z Y Z7 <br /> ADDITIONAL COMMENTS: <br /> MMSE II GROUT INSPECTION ' <br /> PHASE III FINAL INSPECTION <br /> ,INSPECTION BY DATE /:" : % INSP,ECTION BY DATE %ZZ <br /> ~E H, 1426 - Rev.^ 1-74 <br /> .1-74 2M <br />