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SA JOAQUiN LOCAL 'HEALTH DISTRICT <br /> F0A:!'OFFICE USE: 1601 E. Hazelton Ave.. , Stockton, Calif.' " <br /> 1 Telephone: (209) 4666781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. l,�1 <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED`° ' Date Issued . <br /> t( (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fora 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 vl <br /> TRACT ' <br /> Owner's Name; � f / 1-? - ,...�.,,._._. . . _ <br /> R <br /> Phone F2 <br /> Address e _ <br /> y City LA zZLE <br /> Contractor's Name 4 ! 1', <br /> License # L v Phone -,p- 5,i <br /> R <br /> TYPE OF WORK (Check): NEW WELL, DEEPEN /�DEEPERECONDITION- / DESTRUCTION /7 <br /> ' <br /> PUMP ,INSTILLATION REPAIR /_7 PUMP REPLACEMENT 17 <br /> t Other T-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES1 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. SPECIFICATIONSf <br /> industrial p Cable Tool Dia. of Well Excavation /' <br /> ' Domestic/private ;ice Drilled Dia; of--Well Casing... <br /> Domestic/public Driven Gauge,of Casing •-' <br /> Irrigation Gravel Pack DepthYof Grout Seal <br /> _ Cathodic Protection .t. Rotary -Type of Grout } <br /> Disposal ` t Other _rte_ Other Information <br /> __. Geophysical _f <br /> Surface Seal .Installed By: t <br /> PUMP INSTALLATIO Contr cion - <br /> -"%� Type o Pump H.P. <br /> - <br /> / <br /> _ <br /> PUMP REPLACEMENT: / State Work Done <br /> i <br /> . l <br /> State_Work_Done-.._,._._ <br /> ES�TRUCTION OF WELL: Well �Diarneter <br /> 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 GROU G D & FINAL N PECTION, � <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE-) - <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> � I� <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GRQU7 INSPECTION P SEI FINAL NSPECTION k# <br /> INSPECTION BY DATE INSPECTION BY g <br /> E H 1426 Rev. 1-74F�z.0 <br />_- _:� 1-74 2M <br />