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SAN JOAQUI•N LOCAL. HEALTH DISTRICT <br /> EOE OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �-�9'� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE' ISSUED Date Issued q <br /> (Complete In Triplicate) <br /> Application is Aereby 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 /> Z <br /> ' JOB ADDRESS/LOCATION CENSUS TRACT - <br /> Owner's Name Phone 3 <br /> Address _� to-� City 06 <br /> Contractor's Name License # 5 7 Phone ( - <br /> TYPE. OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION /6q�- PUMP REPAIR / / PUMP REPLACEMENT / <br /> _ -�.y..t..��++wf�+.a�.+r.,++tiw�wx+•e�wt .....,w.s :siw.rr..^-.. '.�m . •• 4_ .R -i <br /> Other`s <br /> DISTANCE TO NEAREST: SEPTIC' TANK _ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ! r PROPERTY LINE X PRIVATE DOMESTIC-WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE ;TYPE OF WELL 4 CONSTRUCTION SPECIFICATIONS ! \Cn <br /> Industrial Cable Tool Dia: bf Well Excavation <br /> Domestic/private Drilled Dia.' 6f Well Casing <br /> Domestic/public Driven Gaugeir of Casing ' <br /> Irrigation 41Gravel Pack ! Depth, of Grout Seal <br /> Cathodic Protection 4-1 Rotary j Type of Grout <br /> ;bisposa'1 =' Othe-r Other Information , <br /> `Geophysical /Surface Seal Installed By: <br /> PUMP INSTALLATION: , Contrac•tor: L' <br /> - Type of Pump Sca 4= H.P. <br /> FUMP REPILP(CEMENT: / / State Work Done_ <br /> PUMP .REPAIR: -7j 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 i.strict <br /> and the S'tate of California pertainin9g�to or-t gulating well •construction. Within FIFTEEN DAYS <br /> rafter Completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILL~ERof <br /> STREPORT .the.-well ai�notify them hefore putting the.-well in use. The above <br /> information',is true'"to the best of.iny knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> `PRIOR TO GROUTING AND A FINAL INSPECTION. _ �} <br /> SIGNED ' _ _ _ _TITLE <br /> (DRAW PLOT PLAN ON REVERSE SI ) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I4 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE, II GROUT IN5 CTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION .BY DATE 2i "7 <br /> r , <br /> I/R _ 2M <br /> E H 1426 Rev. 1-74 - - - <br />