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. V SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 01 /1601 E. Hazelton Ave. , Stockton, Calif. <br /> OFFI E USE: Telephone: (204) . 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS:PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> Ik (Complete In Triplicate) <br /> A p licdtion is .hera6y made to the San Joaquin Local Health District <br /> tmade inrcompli nceto construct <br /> with San Joaquin <br /> pp <br /> and/or install the work herein'described. This application <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District.. <br /> i', CENSUS TRACT <br /> JOB ADDRESS/LOCATTON o`��o G' <br /> r Phone <br /> k <br /> Owner's Name m � <br /> Citp <br /> Address r <br /> License # t 3 hone <br /> Contractor.,,s Name " = <br /> L C <br /> 1 h _ <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN / T RECONDITION I PUMP PLpCIEMEN�/� w- <br /> PUMP INSTALLATION / / PUMA' REPAIR /� <br /> I <br /> Other I I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE AISPOSAL FIELD GESSPOOL/SEEPAGE PIT OTHER R� <br /> STIC WELL <br /> PROPERTY LINE - PRIVATE-.DOMESTIC WELL CONSTRUCT� <br /> ION SPEBLIC CIFICATIONS <br /> INTENDED <br /> . <br /> INTENDED USE TYPE OF WELL - <br /> Industrial Cable Tool Dia. of Well Excavation <br /> L <br /> X�r Domestic/private Drilled Dia. of Well Casing <br /> -�- Domestic/public - Driven Gauge of Casing <br /> F Irrigation �- Gravel Pack. Depth of Grout Seal <br /> Type of Grout <br /> + : Cathodic Protection <br /> Rotary ®ch <br /> Other Information <br /> t <br /> Disposal ,:, Other � _ <br /> Surface Seal Installed By. <br /> Geophysical <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACES / / State Work Done <br /> j PUMP *REPAIR: 0 State Work Done <br /> Approximate Depth <br /> ES-iRUCTION OF WELL: Weil Diameter <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San aq <br /> . ouin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within 'FIFTEEN DAYS <br /> F after completion of my work on a new well, I will furnish the San Joaquin Local Heehaboverict <br /> WELL DRILLERS REPORT of the -well and notify them before putting the.-well in use.. <br /> information is true to the best of my k wledge nd b ief. I WILL CALL FOR A'GROUT INSPECTION <br /> PRIOR TO TING ANDFI INSPECTI TLE <br /> SIGNED (DRA P ON SE SIDE <br /> R DEPARTMENT USE ONLY <br /> i PHASE I of oe - DATE . <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE 111/,FINAL INSPECTION <br /> PHASE II GROUT INSPECTION DATE ~ � <br /> INSPECTION BY I DATE INSPECTION $Y <br /> 1-7.4 e2M <br /> 4 E R 1426 Rev., 1-74 <br />