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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE WFICE-USE: 1601 E. Hazelton Ave. , Stockton, Calif. op <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 7 Zdtl;, <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 CENSUS TRACT <br /> Owner's Name Phone <br /> Address I d City <br /> Contractor's Name i^t' df- TX. b P License # Phone <br /> s <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/_/ RECONDITION /_/ DESTRUCTION /? <br /> PUMP INSTALLaION / / PUMP RE IR / / PUMP REPLACEMENT <br /> Other / �'s ►- r'�cr n Vi` 0-,-,�Ki�h <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 SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation 2 <br /> Domestic/private —�� Drilled Dia. of Well Casing a <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> isposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well 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 /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED` TITLE [� <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR EPART <br /> .PHASE I A fMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE a / <br /> ADDITIONAL COMMENTS: t I 4Z <br /> PRASE II GROUT INSPECTION PHAS /FINAL INSPECTION <br /> INSPECTION BY DATE -� INSPECTION DATE / <br /> Y / _ y .f <br /> E H 1426 Rev. • 1-��/ l` 3'Y �'r'�G�A bf 7 2M <br />