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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: x1601 E. Hazelton Ave. , Stockton, Calif. <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/�7 <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 V CENSUS TRACT <br /> Owner's Name �` Phone <br /> Address 1;t111 <br /> ;` `•%�;�•<�, ` '� <br /> City <br /> Contractor's Name !- f 2 �,4 License # /1.0 Phone '�Z,� <br /> TYPE OF WORK (Check) : NEW WELL /,W DEEPEN/ / RECONDITION /-7 DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / ; <br /> DISTANCE TO NEAREST: SEPTIC TANK o-3 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 SPECIFICATIONS r <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing L <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation g Gravel Pack Depth-of- Grout Seal JW <br /> Cathodic Protection Rotary Type of :Grout ` ^ <br /> - fg <br /> Disposal Other y� <br /> Other Information a <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor c <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br />]ESiRUCTION OF WELL: We11 Diameter 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 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 /> information is true to the best of- my knowledge and-belief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TOMROqTIq.CF AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br />?RASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS:. <br /> P S I GIMT INSPECTIO P SE /FINAL INSPECTION <br /> INSPECTION BY , DATE 2 rZ 1 INSPECTION BY DATE <br /> E H 1426 Rev. 1 .7.4 v--� 1 177 <br />