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r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0F%OFFr-E USE: 1601 E. Hazelton Ave. , Stockton, Calif---%�- r <br /> , <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. r� <br /> THIS PERMIT EXPIRES I. 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 Sthe .Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION '3 } l 1 CENSUS TRACT <br /> Owner's Name ! G �. _ Phone —: 3 <br /> Address 3 1 1 City XM F&.'� <br /> f <br /> Contractor's Name ,u). LicensePhone 4 <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 /> PROPERTi LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> , T.NTENDED USE TYPE OF WELL �- CONSTRUCTION SPECIFICATIONS <br /> a...,industrial I Cable Tool' Dia. of Well Excavation <br /> "ki-I'Domestic/private, -I Drilled.- Dia. ,of Well Casing <br /> --Domestic/public t Driven 2. Gauge of ,Casing' - -1 <br /> �"vlrrigation, Gravel Pack Depth of Croat Seal ' - ' <br /> Cathodic Protection 14 Rotary Type:of Grout' <br /> Disposal ! Other Other Information <br /> Geophysical. Surface Seal Installed -By: <br /> PUMP INSTALLATION: Contractor 3u,:neL//c /F- <br /> Type o:E Pump H.P. <br /> PUMP REPLACEMENT: / / Slate Work Done <br /> PUMP -.REPAIR: / / Slate Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure _ <br /> I hereby agree to comply withiall 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 /> informatioplis true to the bes of A9 knowledge and belief. I WILL' C OR A GROUT INSPECTION <br /> PRIOR TO TING kNp A FIN L NSP .'TION. j <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID { <br /> FOR PRFMMENT USE OIJLY <br /> PHASE I <br /> APPLICATION ACCEPTED B DATE <br /> ADDITIONAL COMMENTS, <br /> PHASE II GROUT INSPECTION PHASE I/FINAL INSPECTION <br />'. INSPECTION BY DATE - INSPECTION BY DATE <br /> 0,/77 . 2M <br /> E H 1426 Rev. - 1-74 <br />