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9 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ii Telephone: (209) 466-6781 <br /> i' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> j: yRES l YEAR FROM DATE ISSUED <br /> Date Issued <br /> . THIS PERMIT EXPI <br /> (Complete In Triplicate) <br /> i, permit to construct <br /> Application is�' hexeby made to the San Joaquin Local Health <br /> application is incompliancepliance with San Joaquin <br /> and/ox installs the work herein described. This pp <br /> Count Ordinance o. 1862 and the Rules and Regulations of the San Joaquin Local Health Distr ct. <br /> 1�o � /�'� CENSUS TRACT <br /> JOB ADDRESS/LOCATION ,S <br /> Name <br /> Phone b D fe <br /> Owner's Na <br /> �i City <br /> Address <br /> License Phone...,) C N <br /> IUC— <br /> Contractor's Name <br /> WORK (Check) : NEW WELL I DEEPEN/ I RECONDITION_/ <br /> TYPE OF � DESTRUCTION /� <br /> !� PUMP INSTALLATION // PUMP REPAIR PUMP REPLACEMENT �T <br /> i OtherI/ / <br /> PIT PRIVY ` <br /> DISTANCE TO NEAREST: SEPTICiTANK SEWER LINES _ — OTHER J <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL <br /> PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE 4F WELL CONSTRUCTION SPECIFICATIONS �, <br /> Industrial Cable Tool Dia. of Well Excavation <br />'i Domestic/private Drilled Dia. of Well Casing <br /> I Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Other Information <br /> Disposal Other <br /> Geophy"ical Surface Seai Installed B <br /> l0 <br /> PUMP INSTALLATION: Contractor H.P. <br /> ' Type4of Pump <br /> PUMP-REPIrACEMENT-: //�u/ -S-tate--Work-Done-- <br /> ,� '5tate Work Done <br /> A <br /> PUMP .REPAIR: ^ <br /> � � �_ <br /> JJ Approximate Depth _ <br /> DESTRUCTION11OF WELL:. Welly Diameter <br /> Y Desc'rib�e Material and Procedure <br /> is - <br /> I hereby agree to comply with all laws and regulations owelleconstruction.Local <br /> WithinaFIFTEENDistrict <br /> DAYS <br /> and the State of California pertaining to or regulating <br /> after completion of work on a new well, Iwi <br /> themlbeforesputtingh the atheowellninouseHeThehaboverict a <br /> F WELL DRILLERS REPORT of the well and y <br /> wledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> informations is true to the best of my-kna <br /> PRIOR TO GR0VXNGo.AND A F INSP CTION.10 <br /> TITLE <br /> SIGNED i <br /> i� <br /> W PLbT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> �✓ '� <br /> F PHASE DATE <br /> I ;y. •�� ,-- <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> �� PHASE III/FINAL INSPECTION <br /> PHASE II GROUT INSP TION INSPECTION BY DATE <br /> INSPECTION By DATE <br /> 3/76 2M <br /> E H 1426 Rev. 1-74. <br />