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f% SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 4 FOTO OFFICE USE: �6O1 E. Hazelton Ave. , Stockton, Calif. <br /> i Telephone: (209) 466-6781 <br /> APPLICATION FOR-WELL CONSTRUCTION OR PUMP PERMIT Permit No. la-c2/ <br /> I THIS .PERMIT EXPIRES l 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 /> and/or install the work herein described. This application is made in compliance with San Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION f CENSUS TRACT '- <br /> Owner's Name - Phone , S' �9� <br /> Address _ '� �� d�-n- r> x�/� � ,w_ - City '. <br /> F Contractor's Name a License # Phone <br /> TYPE OF G10RK (Check) NEW WELL /-7 DEEPEN /7 RECONDITIONY%f DESTRUCTION ( <br /> PUMP INSTALLATION PUMP REPAIR '/7 PUMP REPLACEMENT f <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER \ <br /> PROPERTY LINE-- PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial r: 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 9 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: <br /> .L/ /t - State WorkDone <br /> _. ._. <br /> UE&TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> d <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''construetion. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District i <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 -4-1 J <br /> i DRAW PLOT PLAN ON REVERSE SIDE) <br /> f FOR DEPARTMENT USE ONLY <br /> PHASE I 44' <br /> APPLICATION' ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: t <br /> PHASE If GROUT I SPECTION PHASE III INAL INSPECTION F <br /> INSPECTION BY DATE INSPECTION BY DATE - 21 <br /> E H 1426 Rev. 1.-74 -- rr - h/75 � <br />