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SAN JOAQUIN LOCALHEALTH DISTRICT <br /> EAkc7F C USE: 1601 E. Hazelton Ave.., .Stockton, Calif. , <br /> t <br /> Telephone : (209) 46676781 ���/S�� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT. EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In -Triplicate) <br /> Application is hereby made to the San Joaquin .Loca1 Health District for a permit t.o construct <br /> and/or install the work herein described. This application .is made in 'compliance with' San Joaquin <br /> i County Ordinance No. 1862 and ,the. Rules and Regulations of the San J quin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name �'` 01Phone <br /> M1` Address 4 4=1, . r A a Qge City <br /> Contractor's NamrLicense one <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN. /—/ . RECONDITION /_/ DESTRUCTION /- _ <br />' PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT <br /> Other /-7 <br /> 1 4. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY f <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER a ' <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �L <br /> Industrial <br /> Cable Tool Dia, of Well Excavation ' <br /> Domestic/private Drilled Dia. of Well Casing ( ` t <br />` Domestic <br /> f /public � Driven 4 -Gaug,e 'of Casing <br /> ' <br /> t Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection, Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor C j { <br /> E Type of Pump <br /> H.P. <br />' PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: h / State Work Done [ � <br /> 4Wr � <br />_DES.TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Distract <br /> and the State of California pertaining to or regulating well `construction. Within FIFTEEN DAYS <br /> rafter 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 -f my knowle,1 e, and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO 0 TING AND A FINAL I PE <br /> S IGNE TITLE <br /> F (DRA P OT PLAN REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY .� DATE <br /> ADDITIONAL COMMENTS: ` l <br /> PHASE I GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY �/,� DATE INSPECTION BY DATE 16 Com_ <br /> E H 1426 Rev. , 1•-74 b177 - 2M k <br />