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SAN JOAQUIN LOCAL HEALTH DISTRICT ` <br /> 'F—OF, OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 / <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. lI <br /> E <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued i <br />` = (Complete In Triplicate) <br /> F Application is hereby made to the San Joaquin Local Health District for a pgrmit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquid <br /> Co t din nce No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. '.. <br /> / '/35"88 <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name *_. f + Phone <br /> Address 77 `7 �o � <br /> /_ �I d. _� CCt-, city — <br /> Contractor's Name License ne <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/ / RECONDITION /_/ DESTRUCTION /-J C <br /> S <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT , <br /> Other i/ / a <br /> DISTANCE TO NEAREST: SEPTIC -TANK SEWER LINES PIT PRIVY <br /> E SEWAGEDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <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 F Driven Gauge of Casing <br /> Irrigation j Gravel Pack Depth of Grout Seal (, <br /> Cathodic Protection )(' Rotary Type of Grout ► <br /> Other y Other Information ` <br /> Geophysical. Surface Seal Installed- By: <br /> PUMP INSTALLATION: Contractor ; <br /> ''.. .Type of. Pump ii.P. . <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP -REPAIR: / / State Work Done <br /> lDES•TRUCTION 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 /> i and the State of California pertaining to or regulating well 'construction. ,Within FIFTEEN DAYS w <br /> 4 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 TITLE 1' <br /> i (DRAW PLOT PLAN ON REVERSE SIDE) lor <br /> ( FOR DEPARTMENT USE ONLY <br /> PHASE I - <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: 41&1�1 <br /> PHASE II GROUT INS TION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE -� Z�-� INSPECTION BY vt.� DATE <br /> i <br /> E H 1426 Rev. . 1-74 kc_ <br />