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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOH OFFICE USE: , 1601 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 3--_-3-?fV <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 egu ations of the San Joaq in Local Health District. <br /> JOB ADDRESS/LOCATION US TRACT <br /> Owner's Name ` hone <br /> Address C) City fQ�� <br /> Contractor's Name 40 License A Y2.3 Phon� <br /> tv <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_ ' <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 SPECIFICATIONS y� <br /> Industrial Cable Tool' - Di-a-o--of--Wel-l--Excavation- J <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of. Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> .. ...... - - - <br /> Geophysical Surface Seal Installed By:__._._..,_.r <br /> PUMP INSTALLATION: Contractor _ZQz_�_ <br /> Type of Pump H.P. . S'� <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 owledge and belief. I WILL CALL FOR A GROUT INSPEC TON <br /> PRIOR TO GRO NG AND NSPE ON. <br /> SIGNED TITLE _ 1 <br /> W PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 1 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. • 1-74 <br />