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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F6E.7.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' Sau Joaquin Local Health District for 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 RutkandRegulations <br /> 1bf the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION f '` <br /> CENSUS TRACT <br /> Owner's Name Phone qfc-� V <br /> Addresses <br /> .. Ci , <br /> �l)�( <br /> Contractor's Name _ License 7 3 koae'4969P <br /> - <br /> TYPE OF WORK (Check) f_ NEW WELL /_7 DEEPEN /-.7.,. S ION. <br /> _ IECONDITI N /_� DESTRUCTION /7 <br /> PUMP INSTALLATION / /" PUMP REPAIR . PUMP REPLACEMENT <br /> Other / / <br /> f <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY y " <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT, . OTHER. w r <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE 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 />_ 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 of Pump H.P. : : A . <br /> } <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP..REPAIR: 73f 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 perta- nitf g 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 GROUTING AND A FINAL INSPECTION: <br /> SIGNED <br /> TITLE i k <br /> PLOT PLAN ON REVERSE SIDE <br /> t97 :e> FOR' DEPARTMENT USE ONLY <br /> PHASE I / <br /> APPLICATION ACCEPTED BY�,�.,1,t ��_ , _ �� DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II ROUT INSPECTION; PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE,Q . ' INSPECTION BY DATE ' V .. <br /> E H '1426 Rev. 1-74 - 1177co' 2M <br />