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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOH OFFICE!JSE 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 <br /> Date Issued <br /> Application is Aereby made to the San (Complete e <br /> o quinLocalrHeealth District for a permit to <br /> and/or install the work herein described. This application is made in compliance with nSanuct Joaquin , <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Loca ea th District, <br /> . • E <br /> JOB ADDRESS/LOCA ON <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address 1 �� <br /> R <br /> City <br /> CA(m, <br /> Contractor's Name All <br /> License Phone <br /> TYPE OF WORK (Check) : NEW WELL <br /> L__7 DEEPEN�/ / RECONDITION DESTRUCT]'ON /_7 <br /> PUMP INSTALLATION /X/ PUMP REPAIR / /PUMP REPLACEMENT /7 <br /> Other /% <br /> AISTANCE T'0 NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY � <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT- OTHER1 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELT, PUBLIC DOMESTICLL CNIr <br /> INTENDED USE TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing, <br /> e � omestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal' _ <br /> Cathodic Protection Rotary. `` - .. .. <br /> Disposal Type of Grout" <br /> Other Other Information ! <br /> Geophysical urface Seal Installed By: <br /> PUMP INSTALLATION: I \' <br /> Contractor = <br /> Type of Pump - <br /> Ti.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> ��- <br /> PUMP .REPAIR: State Work Done <br />!ES•TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local <br /> Health <br /> end the State of California t <br /> peraining to or_regulating well construction. -Within FIFTEEN tDAYS <br /> ifter completion of my work on a new well, I will furnish ..the. San Joaquin Local Health District a <br /> FELL DRILLERS REPORT of the well and notify them <br /> before putting the'- well in use. The above ! <br /> nformatio ue to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION ! <br /> RIOR TO G <br /> A FINAL INSPECTION.- <br /> IGNED <br /> TITLE . d i <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEP TMENT USE ONLY <br /> HASE'I ' <br /> PPLICATION ACCEPTED BY DATE <br /> DDITTONAL (10MMENTS: <br /> PHASE II GROUT INSPECTION PHASE II/FINAL INSPECTION <br /> NSPECTION BY DATE INSPECTION BYE DATE <br /> a <br /> E H 1426 Rev. 1-74 - if77 _ ' 2M <br />