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SAN JOAQUIN LOCAL -HEALTH DISTRICT ' <br /> FORiOFFICE USE: 1601 E. Hazelton: Ave:; .Stockton, Calif. <br /> Telephone: �'S.(209) 466=6781 <br /> APPLICATION FOR WELL CONSTRUCTION ORPUMP PERMIT Permit No. a <br /> .. „ . . : <br /> THISPERMIT- EXPIRES, 1 YEAR.. [ ,DATE ISSUED n Date Issued - <br /> u ' , : ? . Y > i� �� i,, .(Complete .In Triplicate)- <br /> .{. , fig , �',',, :, <br /> Application is hezeby made to the San Joaquin,'.Local .Health D:istricV..for ,a.:permit to-construct , <br /> .and/or, install the work herein described... .-Thi-8 application.is made;in compliance with San Joaquin. <br /> County Ordinance No I862,,and, the':Rules .arid;,:Regulations;of,.the San•Joaquin.Local 'Health :District. � <br /> JOB ADDRESS/LOCATION r <br /> ¢ §< ei t CENSUS YTRACT " <br /> Owner s Name ,< �.�.,� s o . . ... �_,.f.p <br /> Phone <br /> Address <br /> r . h. . . City' <br /> Corltraetor'.s` Name <br /> Q�License' g <br /> Phoney <br /> TYPE OF .WDRK (Check) NEW WELL /, "DEEPEN: /? RECONDITION" /, 7DESTRUCTION :J f <br /> PUMP ,INSTALLATION } <br /> /; I / PUMP REPAIR / / ' PUMP REPLACEMENT %f <br /> ` Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ; SEWER LIN ,_ ' <br /> DIST .. �. <br /> r ES ' PIT PRIVY <br /> ` SEWAGE DISPOSAL FIELD`, CESSPOOL/SEEPAGE PIT: OTHER <br /> :PROPERTY LINE PRIVATE <br /> DOMESTIC WELL:' ' PUBLIC DOMESTIC WELL v <br /> INTENDED USE .V .. _.STYPE OF WELL <br /> _ industrial : CONSTRUCTION-SPECTFICATIONS <br /> _> ... <br /> Cable Tool Dia. !of Well Excavation 5 <br /> Domestic/private " Drilled - Dia. 'of Well Casing /,d <br /> DasticJpublic Driven: Gauge of Casing <br /> Irrigation <br /> Gravel; Pack Depth of Grout Seal 4 <br /> Cathodic Protection- -Rotary. Type of 'Grout <br /> Disposal. ,, <br /> Geophysical Other -,....Other Information <br /> _ <br /> Surface 'Seal Installed By: , <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump y H.P. <br /> PUMP REPLACEMENT , . # <br /> / ./ State Work Done <br /> PUMP 'REPAIR: 'State "Work Done - ' <br /> ES'FRiJCTION OF WELL Well Diameter <br /> Describe Naterial'and Procedure s Approximate Depth <br /> Thereby agree to comply with all laws and 'tions of. the San Joaquin Local Health District <br /> and; the State of- California pertaining to or regulating well 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 notifyithem before putting. the..well in use. : The above <br /> information is true to',the-bestir of-'•my knowledge and 'belie <br /> PRIf. I';WILI, CALL' FOR A GROUT N INSPECTIOOR" TO GROt1TIN AND A FINAE, NSPECTION., t <br /> r , .,. �. ..., .. <br /> " TITLE : <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I Y FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: ak DATE <br /> ,PHASE II GROUT INSPECTIO � � 1 <br /> INSPECTION $Y `- ° DATE <br /> PHASE I FINAL I SPECT ON. ; <br /> DATE 7.Sr INSPECTION BY <br /> E H 1426 Rev. 1-74 f <br />