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/ -SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave, , Stockton, Calif. <br /> Jim Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> i 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 an- the Rules -and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS%LOCATION CENSUS TRACT ,. <br /> Owner's Name Phone <br /> Address ti. ���� A City <br /> Contractor's Name jj License # Phone,­S"2?—IM/ <br /> TYPE OF WORK (Check) : NEW WELL _jK DEEPEN / / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <br /> � Other <br /> DISTANCE TO: NEAREST: SEPTIC TANK �-SEWER LINES PIT PRIVY <br /> + SEWAGEIDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC� WEL,L PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �. <br /> Industrial Cable Tool Dia. of Well Excavation 44,0f <br /> Domestic/private Drilled Dia. of Well Casing <br /> .: Domestic/Dubl.ic_ . _ Driven _, Gauge of. Casing, c� � - <br /> --- �" <br /> f. Irrigation . F T Gravel Pack " Dept f�Groutz 5Sea3 <br /> Cathodic Protection i Rotary Type of Grout <br /> Disposal 1 Other Other Information �jzl duouA -- <br /> Geophysica_l Surface Seal Installed By: V — <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump H.P. <br /> PUMP REPLACEMENT: <br /> / / State Work Done <br /> PUMP .REPAIR': 4 / / "State'Work Done <br /> DES•TRUCTION. 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 <br /> WELL DRILLERS REPORT of the well and notify them before putting thewell 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 G OUTING AND A4INAL I P-ECTION. <br /> SIGNED d' atfi <br /> TITLE <br /> a J (bRffl4 POT PLAN ON REVERSE SIDE) <br /> FOR EPARTMENT USE ONLY _ <br /> PHASE I <br /> APPLICATION., ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: F ` <br /> '� PHASE II gROUT INSPECTION PHAS I INAL INSPECTIO <br /> INSPECTION ,BY DATE INSPECTION BY ATE <br /> E H..1426 Rev. 1-74 � wrt/.�o�rtr� - .�G���/� f 376- 2P! <br /> I . <br />