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c� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 0__R7OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (.209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3EcJ . <br /> -1 <br />\ THIS PERMIT EXPIRES L YEAR FROM DATE 'ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made t:o 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 /> .TOB ADDRESSAOCATION v /G�i� CENSUS TRACT <br /> 4 <br /> Owner's Name ...�,. Phone f ZL <br /> Address <br /> city <br /> Contractor's Name icense #�9WQJ'Phone 'ZZ2-3�a s <br /> i <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN -/-7 f RECONDITION / DESTRUCTION %f <br /> 1�. PUMP INSTALLATION / 7 PUMP REPAIR '/�. PUMP REPLACEMENT <br /> Other�'/ /. - _. .. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> /Yp�YGr ' SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> VI_ PROPERTY LINE - PRIVATE DOMESTIC .WEILL' PUBLIC DOMESTIC WELL r� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Ri able Tool Dia. of Well Excavation <br /> Domestic/private -tDrilled Dia. of Well Casing <br /> ..__ �omestic/public 'Driven Gauge of Casing <br /> r/ �Lrri,gation :_. : Gravel Pack Depth of Grout Seal. -�-� <br /> Cathodic Pr_oted ion —;Rotary Type of Grout : <br /> Disposal Other Other Information <br /> P <br /> -S'-- ical. - <br /> Geo h sSurface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump w - H.P. <br /> PUMP .REPLACEMENT: /�tate Work Done <br /> . <br /> PUMP .REPAIR: s <br /> . /—/. State Work. Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> ., {..�, <br /> I hereby agree to comply withiall 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 <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 GROUTING AN A FINAL 'INSPECTION. <br /> SIGNED TITLE <br /> .(DRAW PLOT PLAN ON REVERSE SIpE� <br /> PHASE I ._- <br /> FOR DEPARTMENT USE ONLY <br /> - :-JF� �7 <br /> APPLICATION ACCEPTED BY f DATE S <br /> ADDITIONAL COMMENTS: t <br /> PHASE II GROUP` INSPECTION V PHASE III FINAL INSPEC O <br /> INSPECTION By DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1--74 f - h/75 2M <br />