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60 �� fi SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOE OFFI USE: f4'1601 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 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 /> 3 .. <br /> JOB ADDRESS/LOCATION C' _ B me..( CENSUS TRACT <br /> Owners Name a Phone <br /> Address City <br /> ' , License # / -7Y hone r .! <br /> Contractor's Name <br /> 1 _ <br /> F TYPE OF WORK (Check) : NEW WELL -/ DEEPEN / / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION X/ PUMP REPAIR/ / PUMP REPLACEMENT LY <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 <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 /> F Disposal Other Other Information ' <br /> Geophysical. Surface Seal Installed By: <br /> PUMP INSTLATION: � C <br /> ALontractdr - E � r �! <br /> i Type of Pump aAlt" 96 <br /> H.P. <br /> r <br /> PUMP REPLACEMENT: I kl StatetWork Done e L r.-� <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 m "'krn wle ge. -amid' lief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO T NG AND FINAL INSPE ON. <br /> SIGNED TITLE ,► <br /> �. RA T'?1M 'ON RE SE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE 111GROUT INSPECTION PHASE III, FINAL INSFE TION <br /> INSPECTION BY DATE INSPECTION BY p DATE , ` <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 ' <br />