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/ SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOF� OFFICE USE: 1601.E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> . APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2Z-_Zlvfe <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 /> County Ordinance No. 1862 and the Rules nd Regulations of t e San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION --` ' - ¢ CENSUS TRACT _ <br /> Owner's Name ` _-rYf Phone <br /> Address city ' <br /> f + <br /> ' , License �����4�3�� Phone!f`�7� <br /> Contractor s Name <br /> i <br /> T DESTRUCTION DEEPEN / / RECONDITION / / <br /> TYPE OF WORK (Check) : NEW WELL / / r � <br /> PL1M1'INSTALLATION /�"%/-:PUMP 'REPAIR "/:/ PUMP;REPLACEMENT , <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY \ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL O <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> 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 /> a r- ✓� <br />{ PUMP INSTALLATION: Contractor'--tel ---i'�-' <br /> J <br /> Type of Pump H.P. _ <br /> � 1 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter pp <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin ,Local Health District <br /> and the State of California pertaining to or regulating well'constructi.on. 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 before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. I WILL C _ L FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND; FINAL INSPECTION. <br /> SIGNED � --� TITLE <br /> DRAW- 1'LOT PLAN REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> DATE <br /> APPLICATION ACCEPTED BY ! <br /> ADDITIONAL COMMENTS: <br /> k PHASE II ROUT INSPECTION P S I/FI INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE Z <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />