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t SAN JOAQUIN LOCAL HEALTH DISTRICT f <br /> FOF��OFFICE USE: f/ 1601 E. Hazelton Ave. , Stockton Calif. t <br /> Telephone: (209) 466-6781 7C - <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued <br /> (Complete In Triplicate) <br /> k.Applicetion 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 Joaq� <br /> f County Ordinance No. 1862 and the Rules a d Regulations of the San Joaquin Local Health District <br /> 0 Z- A/ �asPr/o <br /> JOB ADDRESS/LOCATIO <br /> Owner's Name <br /> Phone <br /> Address Z 41 01 <br /> City 1 <br /> Contractor's Namef/' <br /> r License,. . 5- hone <br /> TYPE OF WORK (Check) : NEW WELL L77--DEEPEN /y-7 RECONDITION DESTRUCTION /" <br /> PUMP INSTALLATION / ,� PUMP REPAIR -/? PUMP REPLACEMENT <br /> Other C7 -- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE.-DISP SQ AL F-IELD - CESSPOOL/SEEPAGE PITOTHER A, <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL '--- PUBLIC DOMESTIC WELL }� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 4----Cable Tool Dia. of Well Excavation <br /> I Domestic/private Drilled Dia. of Well Casing <br /> ~Domestic/public _,. Driven Gauge of Casing <br /> F <br /> Irrigation Gravel Pack Depth of Grout Seal, <br /> Cathodic Pry otection' Rotary <br /> Disposal Othera Type o£ Grout <br /> Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION.- Contractor <br /> Type of Pump <br /> H.P. <br /> PUMA REPLACEMENT / / State Work DJne <br /> PUMP REPAIR: State Work Done . . . . . <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> k <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 of. my..knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO G AND A F INSPECTION. <br /> SIGNED � , <br /> ' <br /> DRAW TITLE PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY C DATEt/ <br /> ADDITIONAL COMMENTS: <br /> P IT GROUT INSPECTION PHASE I I FI AL INSPECTION <br /> 42 <br /> INSPECTION BY DATE INSPECTION BY DATE 2 <br /> E H 1426 Rev. 1-74 . , r' lJz� �C6 <br />