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SAN JOAQUIN LOCAL HEALTH DISTRICT r. <br /> F(?$iOFFICE USE: 1601 E. Hazelton. Ave. , Stockton, Calif. <br /> Telephoner (209) 466-6781 <br /> APPLICATION FOR WELL CONS'TRUC'TION OR PUMP PERMIT Permit No. 7,6-�/per � <br /> .s THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ;'� ('Complete In Triplicate) <br /> A �rlication is hereby made tolthe San Joaquin Local Health. District for a permit to construct <br /> and/or install the work herein described. This application is wade in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> :SOB ADDRESS/LOCATI 6 cc� CENSUS TRACT <br /> Owner's Name Phoned <br /> Address City ` <br /> Contractor's Name "� License # Vee Phone ,( <br /> TYPE OF WORK (Check) : NEW WELL/_7 DEEP -7 RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR /-7 PUMP REPLACEMENT <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 D � <br /> Industrial i Cable Tool Dia. of Well Excavation �� Q <br /> Domestic/private i Drilled Dia. of Well Casing <br /> Domestic/public I Driven Gauge of Casing <br /> Irrigation I Gravel Pack Depth of Grout Seal <br /> Cathodic Protection i Rotary Type of Grout <br /> — Disposal 6 Other Other Information - <br /> Geophysical Surface Seal Installed By: <br /> egr <br /> PUMP INSTALLATION: Contractor 4d� <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done . <br /> PUNS !REPAIR: /� State Work Done <br /> .- - <br /> VES:TRUCTION OFWELL: Well Diameter Approximate Depth <br /> Descrilie 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 FORA GROUT INSPECTION <br /> PRIOR To GEOUTING FINAL INSP CTION. ,per <br /> SIGNED TITLE I <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> * <br /> FQR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE` <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONrI PHAS I/FIN INSPECTION <br /> INSPECTION BY � DATE � 0. INSPECTION- BY DATE 411017 b " <br /> st R H 1426 Rev-1-74A�+ 2M �i <br />