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rlrV/Iff SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> s FOE;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. � � 21a <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR MELV CONSTRUCTION OR PUMP PERMIT Permit No. . <br /> /THIS PERMIT TRE 1 YEAR FROM ATE f5 LDv <br /> Date Issued <br /> (Complete In Triplicate) <br /> iApplication is hereby made to the Sun 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 Joaqui <br /> , County Ordinance No. 1662 and the Rules and Regulations of <br /> the an Joaquin L cal lth District. <br /> JOB /LOCATION �lll� <br /> NSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address <br /> . City - , <br /> Contractpxs NameS, y ��� <br /> License ���lPhone�✓�� <br /> TYPE OF WORK .._ . _. i_ - _._ <br /> (Check). NEW WELL L7 DEEPEN -/7 RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION "/_7PUMP REPAIR -/_7 PUMP REPLACEMENY/? <br /> Other i77 <br /> ? DISTANCE TO NEAREST: SEPTIC TANIt f SEWER LINES <br /> . SEWAGE DISPOSAL FIELD r- '-PIT PRIVY -� <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE "pRIVATE DOMESTIC WELL/.M'{PUBLIC DOMESTIC WELL-- <br /> Industrial <br /> INTENDED USE TYrE uF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool <br /> _ Domestic/private Drilled Dia. of Well Excavation <br /> Dia. Of Well Casing <br /> 1' r <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 <br /> Geophysical --�._. . Other In€ormation <br /> Surface Seal Installed .B i <br /> PUMP INSTALLATION: Contractor <br /> Type. .of Pump <br /> _ H.P. <br /> PUMP REPLACEMENT: <br /> Ll State Work Done <br /> PUMP !REPAIR: / / :State Work Doris ' <br /> DESTRUCTION OF WELL: Well Diameter 1 <br /> �_ . Approximate Depth <br /> fE <br /> Describe Material and Procedure. ;r-- p "9 L <br /> I I hereby agree to comply with all laws and regulations of the S <br /> and the State of California pertaining to or regulating well"construction.Local Withinalth FIFTEENtDAYS- <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. i.n.use... The above <br /> information is' true to the,best.of" my..knowledge and belief. <br /> PRIOR TO I WILL CALL FOR A GROUT INSPECTION 1 <br />( GROUTING�'AMD A FINAL INSPECTIO v <br /> SIGNED .. � <br /> ( PLO P ON REVERSE SIDE <br /> PHASE I 0 D ARTMENT USE ONLY <br /> APPLICATION ACCEPT ; <br />. ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY _ DATEPHASE III FINAL INSPECTION <br /> INSPECTION BY DATE ,��- " <br /> E H 1426 Rev. .1-74 <br />