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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORIOFFIGE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.�lo_/S�w j <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3 <br /> (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 Joaquin <br /> County ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LM CENSUS TRACT <br /> '�G� <br /> Owner Ps Name � Phone j <br /> Address S City <br /> r <br /> Contractor's Name ID Y1414dt L� License 7,40Phone <br /> TYPE OF WORK (Check): NEW WELL/_7 DEEPEN '/ff RECONDITION q DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / 7 PUM' REPLACEMENT f7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT 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 Cable Tool Dia. of Well Excavation <br /> jV . Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing c., { <br /> Irrigation Gravel Pack Depth of Grout Seal 44 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor J <br /> Type of Pump H.P. <br /> a - <br /> PUMP REPLACEMENT: %/ State Work Done <br /> PUMP :REPAIR: /? State Work Done <br /> ES•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 /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> 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. T WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED <br /> D W PLOT P12WON REVERSE SIDE <br /> FOR DEPAXTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY DATE 3 -,7-9 <br /> ADDITIONAL COMMENTS: . <br /> PHASE II GROUT INSPECTION PHASE I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE b -1 <br /> E H 1426 . Rev. 1-74 1-74 2M <br />