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'� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE XI/ 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. - �' Q <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued 1-95-7 7 <br /> (Complete In Triplicate) <br /> Application is Aereby 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 Joaquin- <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> / CENSUS TRACT <br /> Owner's Name ,� �"' Phone <br /> Address _ r �1a -� City ' / ,S <br /> Contractor's Name q L c rf License # �WPhone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN%/ RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR /—/ PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ~' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS i <br /> Industrial Cable Tool Dia, of Well Excavation i <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing (Q <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> i <br /> Disposal Other Other Information 7 <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. . . <br /> PUMP REPLACEMENT: / State Work Done -A ,l I pTAS <br /> PUMP -.REPAIR: / / State Work Done <br /> DESTRUCTION 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 <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR:OUIMIG AND A FIN L INSPECT ON, <br /> SIGNED TITLE l*�' <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: — <br /> PHASE II GROUT INSPECTION PHA E III/F, NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 11177 2M <br />