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ISAN JOAQUIN LQCAL REALTH DISTRICT <br /> FoRiOFFICE USE: 1601 E. Hazelton Ave. ,,;Stockton, Calif. iM <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I" Date Issued �2 '-� <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit- to construct <br /> and/or.i.nstall the work herein described. This application is made in compliance with San Joaquin : <br /> County Ordinance No. .1862 and the Rules and Regulations of the San Joaquin Local Health' District. <br /> I <br /> JOB ADDRESS/LOCATION /f�� CENSUS TRACT <br /> �p <br /> OwnerPs Name Phone <br /> Address 3 <br /> Contractor's Name License # 29081- Phone 522-1011 <br /> TYPE: OF WORK (Check) : NEW WELLXALTION <br /> DEEPEN /� RECONDITION /� DESTRUCTION /_7 <br /> PUMP INS / / PUMP REPAIR / / PUMP REPLACEMENT 17 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY i� `V <br /> ' SEWAGE ;DISPOSAL FIELD CESSPOOL/.SEEPAGE PIT .j OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation ��- <br /> t/Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> 'Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection L_,Rotary Type of Grout' _-- <br /> Disposal i Other _ Other Information 1i <br /> "' Surface Seal Installed By: <br /> Geophysical _ '. � - �` <br /> PUMP INSTALLATION: ! Contractor F. <br /> Type .of Pump H.P. <br /> 4 / / Ik <br /> PUMP REPLACEMENT: State Work Done_ <br /> PUMP.'.REPAIR*., <br /> PEST:RUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material. and Procedure <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 i <br /> information is true to the-best of my knowledge and belief.. I WILL CALL] FOR-A-GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. I� <br /> SIGNED os Drillin Co. Inc. b TITLE Seco <br /> i (DRAW PLOT PLAN 'ON REVERSE SIDE <br /> r FOR DEPARTMENT USE ONLY ! <br /> PHASE I <br /> APPLICATION ACCEPTED BY �(�`` DATE <br /> I4 ADDITIONAL COMMENTS.*(l- S{ <br /> PHASE ji pROUT INSPECTIO PHAS II'FINAL INSPECTION <br /> INSPECTION BY DATE 7 �/S- �J _ INSPECTION BY DATE -15 <br /> ~E H 1426 Rev. 1-74 iM 1-74 2M <br />