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r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> f FOH OFFICE USE: 1601 E. Hazelton Ave. , Stockton,- Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;76 <br /> � <br /> 'THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ;.I (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health, District for a permit to construct <br /> andjor install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinaxice 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 s City <br /> Contractor's Name License # Phone <br /> TYPE OF- WORK (Check) : NEW WELL/� DEEPEN / RECONDITION I / DESTRUCTION /� <br /> PUMP INSTALLATION '/ / PUMP REPAIR / I PUMP REPLACEMENTRT <br /> Other <br /> f DISTANCE TO NEAREST: SEPTIC TANK jrv•_ SEWER LINES $10 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL �y <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 4 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodie 'Proteetion 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. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: J / State Work Done <br /> DESTRUCTION OF WELL Well Diameter r Approximate Depth { -` <br /> Describe Material and Procedure <br /> R <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 workona new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the Iwell 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 UTING D. A FIN INSPECTION. <br /> SIGNED TITLE <br /> D W PL T- PLAN ON REVERSE SIDE) <br /> f FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE /,2 -,30 <br /> � ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE ZII/FINAL INSPECTION <br /> INSPECTION BY I DATE INSPECTION BY r�/l DATE -27 <br /> . - , � • - 3/76 ZM <br /> t E H 1426 Rev. . 1--74 - - <br />