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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THISPERMITEXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> 1107,-6-ibW (Complete In Triplicate) <br /> Application is hereby I de 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 IV CENSUS TRACT/e"7--`FSO--D/ <br /> Owner's Name 4Phone <br /> Address 22 City <br /> Contractor's Name License # Phone ' <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /% RECONDITION f-1 DESTRUCTION /-7 .� <br /> PUMP INSTALLATION % PUMP REPAIR / / PUMP REPLACEMENT /-7 �] <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 . <br /> Industrial Cable Tool Dia. of Well Excavation C <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor it <br /> Type of Pump !► H.P. Q <br /> PUMP REPLACEMENT: . / / State Work Done <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 GROUP <br /> G D FI INSPECTION. <br /> SIGNED TITLE <br /> DRAW Pi, T PLAN ON RE'V'ERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE`l ''T 7� <br /> ADDITIONAL COMMENTS: " <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE!/,/ <br /> E H 1426 Rev. 1-74 ' <br /> 3/76 2M <br />