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Y7 "" SAN JOAQUIN tLOCAL'HEALTH DISTRICT - - <br /> FORtOFFICE. USE: 1601 E. Hazelton Ave': , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. - a <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Applicidtion is hereby made toithe 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 /> A <br /> JOB ADDRESS/LQCATION l' CENSUS TRACT <br /> Owner's Name Phone <br /> Address _. -- <br /> City <br /> Z z--1 03 <br /> Contractor's Name otos License Phone y1T__0 C <br /> TYPE OF WORK (Check): NEW WELL :/PT DEEPEN '/7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /-7 PUMP REPLACEMENT / <br /> Other '/ / <br /> f <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELLPUBLIC DOMESTIC WELL a <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS v <br /> Industrial I Cable Tool Dia. of Well Excavation <br /> —7— Domestic/private Drilled Dia. of Well Casing All y <br /> . ...: _.. Domestic/public = Driven Gauge of Casing----;-- -�- _. .� . .. �• <br /> Irrigation i Gravel Pack Depth of Grout Seal <br /> — Cathodic Protection Rotary Type of Grout "' <br /> Disposal i Other Other Information w " <br /> Geophysical 'Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor r <br /> Type of 'Pump1e - _._.,__ " <br /> —_� . H.P. <br /> PUMP REPLACEMENT: / IT State Work Done_ <br /> PUMP '.REPAIR: ' /? State Work Done <br /> ES-'£RUCTION OF WELL: Well Diameter Approximate Depth <br /> Descri�e Material and Procedure <br /> I hereby agree to comply with',all laws and regulations of the San Joaquin Local Health District <br /> 4 <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 /> informat on is true to the-best•of my knowledge and belief. I WILL CALL FORA GROUT INSPECTIO <br /> PRIOR G TING D A IN ON. <br /> SIGNED Z,ZTITLE <br /> D PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> 6 <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE (� �--- <br /> ADDITIONAL COMMENTS: r <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTIO 11_�_kW' <br /> INSPECTION BY DATE _ INSPECT ION BY Zc�— DATE�,� <br />��. E H 1426 Rev. 1-74 -74 2N <br />