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EOR OFFICE USE: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> # 1601 E. Hazelton Ave. , Stockton <br /> i <br /> Telephone: Calif. <br /> P <br /> APPLICATION FOR WM*-CONSORUCTION6OR1PUMP <br /> PERMIT Permit Na. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> A .I( Complete In Triplicate) Date Issued <br /> PPlicati <br /> on is hereby made to the San Joaquin Local Health District for a permit to e <br /> and/or install the work herein described. This a <br /> pplication is made in compliance withnSanuct <br /> Jo <br /> 1862 and the Rules and Regulations of the San Joaquin Local Health District.County Ordinance No, t. <br /> JOB ADDRESS i <br /> ! Owner's Name CENSUS TRACT <br /> /D ' <br /> rs <br /> t <br /> Address . Phone <br /> `( <br /> City <br /> Contractor's Name <br /> License Phone <br /> TYPE OF WORK (Check) <br /> / / DEEFEN /_% RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / PUN? REPLACEMENT <br /> Other ►fv �- /? e r <br />( DISTANCE TO NEAREST: SEPTIC TANK �0 <br /> SEWER LT ES PIT PRIVY <br /> SEWAGE DISPOS FIELD <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL PUBLIC DOMESTIC WELL�� <br /> Industrial ! Cable Tool CONSTRUCTION SPECIFICATIONS <br /> /Private <br /> Domestic Dia, of Well Excavation <br /> Domestic/Public <br /> Drilled Dia. of Well Casing G <br /> 3 �� a <br /> Irrigation Driven Gauge of Casing f Z <br /> Cathodic Protection Graver Pack = Depth"of' Gro`it 'Seal'" "'— <br /> ____� Ro t a r <br /> Disposal a y Type of Grout <br /> Other Other Information <br /> Geophysical -- <br /> Surface'Seal Installed $ : �° s <br /> PUMP INSTALLATION: t <br /> Contractor J / <br /> Type of Pump <br /> H.P.I, <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: <br /> State Work Done <br />)ES•TRUCTION OF WELL; Well, Diameter <br /> Describe Material and Procedure Approximate Depth <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health <br /> end the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br />(ter completion of my work on a new well, I will furnish the San Joaquin Local HealthDistrict <br /> SELL DRILLERS REPORT of the well and notify them before putting the..well in use. District a <br /> nformation is true to the best of my knowledge and belief. The above <br /> RIOR TO GROUTING AND A FINAL INSpECTIO I WILL CALL FOR A GROUT INSPECTION <br /> IGNED <br /> TITLEi ! <br /> ( PLO REVERSE SIDE) <br /> iASE I FOR DEP TMENT USE ONLY <br />°PLICATION ACCEPTED BY <br />)DITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSP CTION ' <br />[SPECTION BY �- D.`�� DATE P E I/ INAL INS ECTION <br /> INSPECTION BY DATE <br /> E H 1426 Rev. <br />