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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF� OFFICE US E-- 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 Y <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. J --/Lp.4d-elo <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1 <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 Regulations of the San -Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone ' <br /> Address W71 City <br /> Contractor's Name License # ��J'�tij Phone �?S <br /> TYPE OF WORK (Check) : NEW WELL/7 DEEPEN -17 RECONDITION � DESTRUCTION %f <br /> PUMP INSTALLATION /—/ PUMP REPAIR-/7-7—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 � I <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation � I <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 /> Geophysical Surface Seal Installed By: _ . <br /> PUMP INSTALLATION: Contractor <br /> Type YP Pump H.P. <br /> 3 <br /> PUMP REPLACEMENT: , j_/ State Work Done <br /> PUMP '.REPAIR: <br /> /" / State Work Doiae <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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO TING AND A FINAL INSPECTION. <br /> SIGNED TITLE 222 <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 PHASE III INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ;�6 <br /> E H 1426 Rev. i-74- y , , .. r <br /> i,/752Ms <br />