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SAN JOAQUIN LOCAL HEALTH-DISTRICT <br /> FOE OFFICE USE: &41 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) • 466.-6781 1 <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 /> a /or install. the work herein hesRulesdandTResulationstafnis the Sane3oaquinincompliance <br /> HealthSDistrict3n <br /> C unty Ordinance No. 1862 and t 8 <br /> JOB ADDRESS/LOCATION , ,� � 1 CENSUS TRACT ; <br /> Phoney <br /> Owner's Name . �^ <br /> ` _ -� <br /> Address City <br /> Contractor's Name <br /> License 4�`1a.�3 Phone <br /> TYPE OF WORK (Check).: NEW WELL / DEEPEN I / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION -/ PUMP REPAIR ,6f PUMP REPLACEMENT I? <br /> AL <br /> O there / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD _CESSPOOL/SEEPAGE PIT OTHER <br /> a PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial. Cable Tool Dia. dof-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. . w Type of. Grout <br /> Disposal. s...,�. . <br /> i�Other —'..-Other Information ' 11 <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: L / t State Work Done <br /> 1112 <br /> f PUMP REPAIR: ' State Work Done <br /> Z214A <br /> DESTRUCTION 4F WELL: We1I Diameter Approximate_Depth <br /> Desciribe Material and Procedure <br /> I hereby agree to comply w lth all laws and regulations of the San Joaquin LocalHealIFTEEN <br /> District <br /> and the State of California; pertaining to or regulating well construction. With <br /> in FDAYS <br /> after compl"etion'ofmy work on a naw well,-.1 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 ta to the-bes of- my kno ledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTIN rANDI A FIVAJNSPECTIy, <br /> TITLE <br /> SIGNED W..pL T PLAN �ON REVERSE SITE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I e DATE <br /> f APPLICATION ACCEPTED BY �- <br /> ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION 7 <br /> PHASE II GROUT INSPECTION DATE <br /> INSPECTION BY I1 DATE INSPECTION BY <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />