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SAN JOAQUTN LOCAL HEALTH DISTRICT <br /> F—ogtOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> E APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> TRIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued 7� <br /> F� (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,york 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 Realth'District. <br /> f JOB ADDRESS/LOCATION %i - CENSUS TRACT <br /> +i •— <br /> Owner's Name _ Phone <br /> Address City ,pS GAto a <br /> ' _L Sjj l ,� License #.2 X?0/O Phone &� Qaoy <br /> Contractor's Name-! , �. d... � -- <br /> r <br /> TRIPE OF WORK (Check): NEW 1WELL /? DEEPEN -/7 RECONDITION /� DESTRUCTION 17 <br /> i PUMPIINSTA LATION / / PUMP REPAIR / / PUMP REPLACEMENT . <br /> other <br /> } <br /> .DISTANCE TO'`NF.ARFS•T:--S£?T-W-fiANK \ Nf SEWER LINES �PIT PRIVY <br /> I SEWAGE DISPOSAI: FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> iPROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE t TYPE OF WELL ' CONSTRUCTION SPECIFICATIONS <br /> Industrial , Cable Tool /Dia. of Well Excavation <br /> Domestic/private Drilled /Dia. of Well Casing .� <br /> �— Domestic/public Driven Gauge of Casing <br /> t Irrigation , Gravel Pack 1tepth of. Grout Seal <br /> Cathodic Protection } Rotary 7Type of Grout <br /> DisposalOther Other Information <br /> Geophysical 'Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor t <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT-. j7—:—State Work Done u . r - <br /> 'PUMP---REPAIR: "" / '"state woik Doha < <br /> .DESTRUCTION OF. WELL: Well Diameter # �Approxfmate Depth <br /> �� Describe Material and Procedure \ 1 <br /> I hereby agree to�comply with all laws and regulatiotis 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 J6 qui <br /> Realth:.District e <br /> WELL DRILLERS REPORT of the well and notify them before putting. the..we-n ln-ruse.. The above <br /> information is true to thebest of my knowledge and belief. I WILL CALL FOR GROUT INSPECTION <br /> PRIOR TO GROUTBIR ANDA FjNAY. INSPECTION. . . <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY � DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P II <br /> .,FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B <br /> I ;4 E H 1426 Rev. 1-74 1-742M <br />