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i <br /> ? SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> FORI'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 <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 dedcribed. 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 c CENSUS TRACT <br /> Owner's Name Phone <br /> Address City -c <br /> I <br /> Contractor's Name e D it in Co. Ine. License # 2 081 Phone 522..1011 � <br /> 2500 W. R30ble lid., Modesto <br /> TYPE OF WORK (Check): NEW WELL LV DEEPEN /_7 RECONDITION /? DESTRUCTION / <br /> PUMP INSTALLATION /% PUMP REPAIR /-7 PUMP REPLACEMENT /_7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY � <br /> SEWAGE DISPOSAL FIELD CESSP00L/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONrn <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private/Drilled Dia. of Well Casing -57,e ` <br /> Domestic/public Driven Gauge of Casing _ /0 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection c-,--Rotary Type of Grout <br /> Disposal other, Other Information <br /> Geophysical Surface Seal Installed BX: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,REPAIR: /? State Work Done _ <br /> ES•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 a <br /> WELL DRILLERS REPORT of the well and notify thew 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 by .- TITLE <br /> Seco <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS& UVEINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION <br /> BYDATE ` <br /> I <br />' '+ E H 1426 Rev. 1-74 1-74 2M <br />