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y TJ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F'OR.OFFICE USE: Z. , <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 i <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> I 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 /> lations of the San Joaquin Local Health District. <br /> County Ordinance No. 1862 and the Rules and Regu <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> Owner's Name Phone <br /> Address City <br /> I License # Phone <br /> x <br /> Con,traetor's Name �:1 --' <br /> TYP$ OF WORK (Check): NEW WELL J-7 DEEPEN -/7 RECONDITION /� DESTRUCTION <br /> PUMP,JINSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> k <br /> Other <br /> DISTANCE <br /> ! / <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 /> I INTENDED USE TYPE OF WELL, CONSTRUCTIQN,.SPECIFICATIONS <br /> {, Industrials" ; Cable Tool Dia. of Well Excavation <br /> Domestic/private f Drilled Dia. of Well Casing <br /> Domestic/public I Driven Gauge of Casing <br /> Irrigation Gravel Pack' Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> DisposalOther Other Information _ <br /> Geophysical # Surface Seal Installed BY: �- <br /> PUMP 'INSTALLATION: Contractor _ <br /> Type; of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP-.REPAIR: / State Work Done <br /> ''�^1II Approximate Dept ISC7 Imo` <br /> ESiRUCTION OF WELL: Well Diameter � L � pp pt��� <br /> Des a to ial a —Pt, cedure 50` <br /> sro� <br /> F, I hereby agree to comply w th all laws and regulations of the San qu n 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 im.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 GROUTIN AND A FIN INSPECTION. TITLE <br /> t SIGNED . <br /> DRAW PLOT `PLAN ON REVERSE SID;?�� <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE ~ �-�0 <br /> APPLICATION ACCEPTED BY St^— - <br /> ADDITIONAL COMMENTS: ; - <br /> t PHASE II GROUT INSPECTION PHAS III F AL INSPECTION <br /> INSPECTION BY : DATEINSPECTION BY DATE <br /> 17 <br /> t <br /> 1-74 2M <br /> E H 1426 Rev. 1-74 <br />