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_ SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE 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 J� <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 Ru s and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 7 CENSUS TRACT <br /> Cie <br /> Owner's Name <br /> t <br /> Phone . <br /> Address <br /> City <br /> Contractor's Name ! License Phoned� - <br /> 6 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/—/ RECONDITION /_7 DESTRUCTION /-T <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 1 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <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 � Ty_pe-of Grout <br /> Disposal µOther Other Information <br /> Geophysical Su-rface Seal Installed" By.c_ <br /> PUMP INSTALLATION: Contractor�/�c � <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Don <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 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 notify them before putting the -well in use. The above <br /> information is true to he best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G OUTING MD A IN L INSPECTION. <br /> SIGNED TITLE <br /> a <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE d <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPkCTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE _5--Z-17d_ <br /> E H 1426 Rev._1-74 <br />