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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDDate Issued / 7cf <br /> (Complete in Triplicate) 0 b3- <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 f?g n.) - A� s TDI <br /> JOB ADDRESS/LOCATION -> / CENSUS TRACT <br /> Owner r s Name Phone 3(a k- <br /> Address City 1-4' <br /> Contractor's Name .. ' License / Phone <br /> TYPE OF WORK (Check): NEW WELL L 7 DEEPEN/7 RECONDITION -/? DESTRUCTION /7 <br /> PUMP INSTALLATION / PUMP REPAIR 0 PUMP REPLACEMENT 17Other L/ — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ,N <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 r <br /> Industrial Cable Tool Dia. of Well Excavation r <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 /> Disposal Other _ Other Information bZ <br /> Geophysical Surface Seal, Installed B <br /> PUMP INSTALLATION: —�'''Iy kj <br /> Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: f7- State Work Done ' <br /> PUMP ,.REPAIR: State Work Done <br /> ES•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 thewell 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 GROUTI12 AND, A FINAIANSPECTION. <br /> SIGNED �,x TITLE d <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE <br /> ADDITIONAL COMMENTS: L;��y <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY f DATE <br /> }i <br /> 4 E H 1426 Rev. 1-74 <br /> 1-74 2M <br />