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{ 1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOk OFFICE USE: 1.601 E. Hazelton Ave. ,- .Stockton, Calif. �� z <br /> Telephone : (209)-, 466 6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -) <br /> THIS PERMIT -EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <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 /> JOB ,ADDRESS/LOCATION ' <br /> CENSUS TRACT p <br /> Owner's Name Phone �� �ory;� <br /> Address <br /> - City � r <br /> Contractor`s Name �'` � <br /> License 1t_� Phone,?-V�//� <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION: /—/ DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR % / PUMP REPLACEMENT <br /> Other / / <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 /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONSr <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing ; <br /> Domestic/public _Driven Gauge of CasingT <br /> Irri. anon,... �T. �.�-' .. _,� �,.� _ .... . <br /> g. Gravel^Pack <br /> Depth of Grout Seal <br /> ---Ca.thad c_.Pro-62c-t to -t--Rotary Type of Grbut ; <br /> Disposal Other Other Information I <br /> Geophysical. Surface Seal Installed By: <br /> PUMP INSTALLAfiION: Contractor <br /> Type of 'Pump H.P. <br />.PUMP REPLACEMENT: / / State Work Done Q <br /> r; <br /> P <br /> PUMP .REPAIR: ' ' <br /> / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 1 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 toor. regulating well "construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well,- f will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them,'befor-e--putting the. well in use... The above <br /> information is true to the best of my'.knowledge azi.d belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR UTING AND A INAL INSPECT-JON. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) _._._. <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I T <br /> APPLICATION ACCEPTED BY c DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPEOIrION PHAS III/FINAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE _ <br /> E H 1426 Rev. • 1-74 <br />