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�13 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F—oK70FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781. <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 Local health District for a permit to construct <br /> and/or install. the work herein described. This application is made in compliance with San Joaquin <br /> Counfy Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local health District. <br /> JOB ADDRESS/LOCATION l� CENSUS TRACT <br /> a <br /> Owner's Name Phone <br /> Owner's <br /> Address S .. City;2l� 0A <br /> Contractor's Name - ' License t :�,>Phono&&_ /. ,-7 <br /> TYPE OF WORK (Check): NEW WELLJl ^DEEPEN /_T'~IECONDITION /7 DESTRUCTION %f <br /> PUMP INSTALLATION /L{�PUMP REPAIR /7 PUMP REPLACEMENT f7 <br /> Other <br /> DISTANCE �TO�NEAREST; .SEPTIC"TANK SEWER LINES PIT PRIVY <br /> 'SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHRR <br /> << PROPERTY LINE -- PRIVATE DOMESTIC WELL' _ PUBLIC DOMESTIC WELL <br /> INTERED, USE TYPE OF WELL- CONSTRUCTION SPECIFICATIONS <br /> si1'f "'trial Cable Tool Dia. of Well Excavation° <br /> ! omestic/private Drilled Dia. of WellCasing <br /> Domestic/public I Driven "" Gauge of_Casing "I <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary I Type of Grout <br /> A <br /> Disposal OtherF Other Information, ;` ..,....,_. <br /> Geophysical ,.. Surface. Seal Installed B <br /> PUMP INSTALLATION: Contractor " <br /> 4 Type of Pump H.P. <br /> PUMP REPLACEMENT:— / / State Work Done <br /> PUMP ,.REPAIR: - State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree, to comply with all laws and regulations of the S n Joaquin Local_-Health.th District <br /> and the State 'of California pertaining to or;regulating well '-co structiod. Wlthin- FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joa4u i Lo eal.th District a <br /> WELL DRILLERS REPORT 1of the well and notify them before putting.the•.well.,iri: 'se-... -The above <br /> information is true .to the-best of my-knowledge and belief. I WILL CALL_k0_A- A GROUT INSPECTION <br /> PRIOR TOG I AND:.•A UM INSPECTION. mom-- 41-'� - <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> a. <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> � ;` � <br /> APPLICATION ACCEPTED BY C DATE 11117e <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION . PHASE IIs FINAL INSPECTION <br /> INSPECTION BY C'/_3 ) DATE 2 : INSPECTION BY DATE <br /> E H .,1426 Rev. 1-74 .moi.__ ._ t_- <br />