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SAN JOAQUIN LOCAL -HEALTH DISTRICT <br /> !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 7 � <br /> (Complete In Triplicate) <br /> Applic4tion is hereby ma'de torthe 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 Joaquii <br /> County Ordinance No. 1.862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION "�:� CENSUS TRACT <br /> Owner v s Name 2� <br /> Phone4z <br /> Address = �� � �_ <br /> City�_-,Xa <br /> Contractor's Name License A/0 _r_�Phone;M � <br /> TYPE OF WORK -(Check): NEW WELL -/_7_ <br /> ELL/7 DEEPEN /7 RECONDITIXj!R. <br /> STRUCTION /`7 <br /> PUMP lINSTALLATION /_/ PUMP REPAIRPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER g <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> IN USE ' TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing p` <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 /> PULP INSTALLATION: ContractorU elf --5Type of Pump A.P. <br /> PUMP REPLACEMENT: / V State Work Done <br /> ' PUMP !REPAIR: State Work Done - - - <br /> ESilUCTION OF WELL: Wel ' .Diameter Approximate De th <br /> Describe Material and Procedure p `— <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 the-Vest of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL, INSPECTION. _ <br /> SIGNED I TITLE <br /> {DRAW PLOT PLAN ON REVERSE SIDE ' ✓""""' <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - DATE <br /> ADDITIONAL COMMENTS: <br /> ' PLEASE II GROUT 'INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION `BY DATE INSPECTION BY DATE <br /> 4 <br /> E H 1426 Rev. 1-74 <br /> . 1-74 9iu <br />