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f' V r ] <br /> SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> I %.. Telephone: (209). 466--6781 <br /> APPLICATION ,FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ] ]. / p , <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . Date Issued `7 <br /> il (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 andlthe Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION " C.-t-fCENSUS TRACT <br /> Owner's Name r� Phone x 9 d., 'S <br />` <br /> Address p City <br /> Contractor's Name s. T License it Phone <br /> a <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_/ RECONDITION /_7 DESTRUCTION /7 <br />` PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other 7_7 — <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 3 CONSTRUCTION SPECIFICATIONS {� <br /> Industrial Cable Tool Dia. . of' Well Excavation <br /> D <br /> omestic rivate Drilled ia, of Well Casing <br /> c <br /> /P Ag \l <br /> Domestic/public , Driven Gauge of Casing <br /> Irrigation Gravel Pack . '-,"Depth of Gfdut" Sea1 <br /> Cathodic Protection :1 Rotary Type 'of Grodt ... <br /> Disposal. i Other Other Information <br /> —Geophysical A` x' Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 0. <br /> Type oaf Pump —� -, - H.P. . <br />' PUMP REPLACEMENT: State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> f+, al -- <br /> DES-TRUCTION 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 isftrue to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR TING'AND A FINAI! INSPACTIQN. <br /> SIGNED TITLE Q`�.C/Yrr�t1^T <br /> ,r <br /> 1 (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ` <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: I <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE _�✓�� INSPECTION BY DATE <br /> i ]I I7 2M <br /> E H 1426 Rev. 1-74 - <br />