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+ ald SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ; _ 7 z ,�__.j <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin. Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT i- <br /> Owner's Name Phone <br /> Address t ` ' City 0ZIove <br /> Contractor's Name License #,2_y,&2rPhone7y <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN '/rT'RECQNDITIQN /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /_7 PUMP REPLACEMENT %f <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK ___jkD 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 <br /> � <br /> Industrial, _, C-able Tool Dia. of Well Excavation <br /> mestic,/private Drilled Dia. of Well Casing r. \ <br /> Domestic/public � Driven Gauge of Casing X <br /> Irrigation Gravel Pack Depth of Grout Seali <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: State Work Done i <br /> PUMP .REPAIR: /7 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 GROUTIN AND A AL N ECT N. <br /> SIGNED TITLE <br /> (DRAW P T PLAN ON REVERSE SIDE <br /> PHASE I R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY rDAT$/ <br /> ADDITIONAL COMMENTS: i <br /> PHASE II GROUT INSPECTIO P S I I F INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. ' 1-74 r_ . L17K 'M <br />