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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR.OFFICE USE: 1601 E.',.\Hazelton Ave. , Stockton, Calif. <br /> T61ephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 1 ' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued (� <br /> (Complete In Triplicate) <br /> Application is hereby made to--tle 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 Joan <br /> County Ordinance No. 1862 and the Rules and Regulations of the San, Joaquin Local Health Distriet. <br /> JOB ADDRESS/LOCATI N r / OzAfrCEN&US TRACT <br /> Owner's Name <br /> Vr� Phone <br /> Address <br /> City <br /> ContractoTle Name License # <br /> Q 7, !4V Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL � DEEPEN /% RECONDITION /-7 DESTRUCTIONr/- � <br /> PUMP INST LATION / / PUMP REPAIR /—/ PUMP REPLACEMENT /-7 ' <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD l��-" CESSPOOL/SEEPAGE PIT-,7�' /-OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrialable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> :( - omastic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal r C <br /> Cathodic Protection RotaryT ---� <br /> Type of Grout _ �, <br /> Disposal Other Other Information _ <br /> Geophysical Surface Seal Installed B 1 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP '.REPAIR: State Work Done �+ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth e <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 DAIS <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 of them before y em ore putting the well in use. The above <br /> information is tru to the best of nowledge and belief. I WILL C L FOR A GROUT IN PECTION <br /> PRIOR TO GROUTING FI INSP ION <br /> SIGNED TITLE <br /> (DRAW PLO AN ON REVERSE SIDE) <br /> FO EPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYE DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 142E Rev. 1-74 � ' 1177 77 _ ' 2M <br />