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47 SAN JOAQUJ-N-LOeAAL HEALTH DISTRICT <br /> FOR OFFICE USE: O ' 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 /> ct <br /> Application is hereby made to the San Joaquin Local Health Distrriictt furca peiancetwithnSanuJoaquin <br /> rmit <br /> and/or install the work herein described. This application <br /> G County Ordinance No. 1862 and the Rut aie Igulations of the San Joaquin Local Health District. <br /> f fi�Gl.l�� G-C,6 CENSUS TRACT ' <br /> JOB ADDRESS/LOCATION d <br /> Phone <br /> Owner's Name <br /> �p City <br /> Address d <br /> Contractor's Name <br /> icenseV f1 Phone <br /> TYPE OF WORK (Check) : NEW WELL /7DEEPEN ./ / RECONDITION / 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 <br /> Cable Tool Dia. of Well Excavation <br /> - " <br /> i L-,-Domestic/private. /,--Drilled <br /> Dia. of Well Casing <br /> ,.� Domestic/public. - Driven _r ;..Gau.ge„sof- Casing <br /> Irrigation Gravel Pack Depth of- <br /> Grout Seal <br /> Cathodic Protection” _ Rotary Type of Grout <br /> Disposal i Other Other Information y � <br /> Geophysical <br /> � , Surface Seal Installed B �+ <br /> .-:; � , <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type#of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> C D S•TRUCTION OF WELL: Well Diameter <br /> .57- Approximate Depth S� <br /> Describe Material and Procedure <br /> e <br /> } . I hereby agree to comply with a laws and regulations of the San Joaquin Local Health District <br /> fand 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 f <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 INSPECTIO <br /> PRIOR TO GROUTING AND F AL INSP CTIO -, ' /7- TITLE l( 9 <br /> SIGNED (�(r <br /> DRAW T P AN 'ON RE ERSE SIDE t `V <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY C/��r DATE <br /> ADDITIONAL COMMENTS: PHASE III/ INAL NSPECTION <br /> PHASE II GROUT INSPECTION . <br /> INSPECTION BY TE �7 <br /> INSPECTION BY ! DATE �, <br /> 3X76 2M <br /> R x 1426 Rev. 1-74 <br />