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SAN JOAQUIN LOCAL HEALTH- DISTRICT ^} <br /> iOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. /a <br /> Telephone: (209) ' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR .PUMP PERMIT Permit No. ,� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued C?� <br />- (Complete In Triplicate) <br /> Application 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 andSan Joaquin <br /> Joaquin Local Health D <br /> County Ordinance No: 1862 ina ns of a San istrict. r <br /> o i _ s and Reg�-, <br /> JOB ADDRESS/LOCATION, I� A9 CENSUS TRACT <br /> ,. . <br /> r <br /> Owner's Name- <br /> Phone <br /> A <br /> Address <br /> - - City - - <br /> Contractor's Name �'J` :. -`License�[�/ <br /> TYPE OF-WORK. ('Check) NEW WELL U,DEEPEN /_% RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION /1�PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> "g �.i ;x •gid", zOther / / ' <br /> DISTANCE TO NEAREST: SEPTIC TANK ^SEWER LINES PIT PRIVY <br /> -SEWAGE DISPOSALELD', . CESSPOOL/SEEPAGE PIT OTHER <br /> "F..ROPERTY LINE PRIVATE DOMESTIC WELL` PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION S_PECIFZICATIONS <br /> Industrial Cable-Too-1 Dia, of Well Excavation ?1 W <br /> e�omestic/private- �, '—Drilled Dia. of Well Casing LIT <br /> Domestic/public . 4 Driven �` _Gauge of Casing 1-2 <br /> Irrigation ! Gravel Pack~ Depth of Grout Seal <br /> Cathodic Protection �atary Type of Grout <br /> AisposalOther Other Information <br /> Geophysical Surface Seal Installed By: r <br /> PUMP INSTALLATION: Contractor <br /> Type: of Pump t .P, <br /> PUMP REPLACEMENT: / / . State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate pp ximate Depth <br /> Describe Material and Procedure <br /> � F , <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District J <br /> and the State of California pertaining to or regulating well 'construction. Within FIFTEEN DAYS <br /> after completion of my work onla new well, I will furnish the San Joaquin Local Health District a R <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 />?RIOR TO GRO TING D A FINAL INSPECTIO , <br /> SIGNED <br /> TITLE _ <br /> (DRAW PLOT PLAN ON REVERSE SIDE} ��� <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I. <br /> APPLICATION ACCEPTED BY �- DATE ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION t; `4 PHASE III/FINAL INSPECTION ' <br /> INSPECTION BY DATE , INSPECTION BYIV <br /> 3 DATE <br /> E H .1426 Rev. 1-74 1117: _ 2M ' <br />