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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-678 . <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE. ISSUED DateIssued _20-76 <br /> (Complete In Triplicate) <br /> Appiication' i,e hereby made do the San Joaquin Local Health District. for u permit_to ,construct <br /> and/or install the work herein described. This application, is made in .compl.iance.with„San-Joaquit <br /> 'County Ordinance No. 1862 grid the Rule@ and Regulations of the Sas: 'Joaquin:,Local Health District. <br /> -JOB ADDRESS/LOCATION �•� -� ` f; ;J < f I s <br /> t- all —CENSUS TRACT <br /> Owner's Name :. Phone <br /> [ Address <br /> f ^ <br /> Contractor's Name License:, Phone.. C. <br /> TYPE -OF WORK (Check): NEW WELL DEEPEN '/7 RECONDITION �j DESTRUCTION /7 <br /> PUMP INSTALLATION 077Pw REPAIR -/� PUMP REPLACEMENT- � <br /> r Other <br /> ,DISTANCE TO NEAREST: SEPTIC TANK SEWS ES( ).-C PIT PRIVY C� <br /> SEWAGEDISPO AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC=WELL <br /> INTENDED USE "TYPE OF WELL CONSTRUCTION. SPECIFICATIONS <br /> Industrial +� Cable Tool Dia. of Well Excavation <br /> Domestic/private : Drilled Dia. of .Well Casing, _ <br /> ` Domestic/public : Driven r <br /> �r�►Ga�ge of Casing <br /> Irrigation <br /> - - . -t Gravel Pack Depth of Grout Seale ' <br /> �a <br /> Cathodic-Pr_otection I Rotary. Type of Grout _... �. „ <br /> Disposal Other Other Information <br /> w <br /> Geophysical �.. Surface Seal Instal,ldd By: <br /> PUMP INSTALLATION: Contractor <br /> z Type i�f Pump H.P. - <br /> ' UMP REPLACEMENT: . <br /> lP / / ' State Work Done <br /> IBUMP .REPAIR: / / State Work Done f <br /> (DESTRUCTION OF WELL: Well Diameter - 9Apptwtimate De th �)O � <br /> Describe Material an& Vracedure . . . <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 /> linformation is true to the,best-of my knowledge and belief. I WILL CALL.FOR A.GROUT INSPECTION <br /> PRIOR TOO.TiNG A� 'IN SPECTION. <br /> SIGNED i/ r>> . TITLE <br /> f .J� DRAW .PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY. <br /> - r ;� � . <br /> APPLICATION ACCEPTED BY DATE 6"^ -� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSDECTIOX' PHAR III/MAL INSPECTION <br /> INSPECTION BY IDATE INSPECTION BY DATE <br /> E H 1426 .> .-, .. . . . _ � <br /> Rev. 174 h175 2M <br />