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k ir1 SAN JOA UIN LOCAL HEALTH ALTH DISTRICT <br /> 0—E,;OFFICE USE: . 1601 E. Hazelton Ave. , Stockton, Calif. <br /> f Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> k � <br /> THIS PERMIT �EXPIRES I YEAR FROM DATE ISSUED Date Issued <br /> fE (Complete In Triplicate) <br /> Application is hereby nada'"10 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 . r'& G CENSUS TRACT <br /> Owner's NamePhone ' <br /> ccs e 5 7 <br /> Address ._ <br /> City' <br /> Contractor's Name <br /> License' !i Phone ' <br /> TYPE OF WORK� (Check): NEW WELL 17 DEEPEN /? RECONDITION /_7 DESTRUCTION <br /> PUMP ,INSTALLATION j / PUMP REPAIR '/-7 . PUMP REPLACEMENT /7 <br /> Other /-7 . <br /> a .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 "1 <br /> _ Industrial > Cable Tool Dia. of Wall Excavation °� <br /> Domestic/private : Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> IrrigationGravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal .i Other Other Information <br /> GeophysicalSurface Seal Installed 'B <br /> PUMP INSTALLATION: - <br /> Contractor <br /> Type. .f Pump <br /> H.P. <br /> PUMP REPLACEMENT: / Mate Work Done <br /> PUMP {REPAIR: 1_7 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe ter al a d Procedure - — <br /> I hereby agree to comply with all and regulations of t1re San Joaquin Locdl Health District <br /> and the State of California pertaining to or regulating we11 'construction. Within FIFTEEN DAYS <br /> lafter' completion of my work on anew well, I will furnish the San Joaquin Local Health District a <br /> IWELL 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 G U NG D A FIN '4�± <br /> INSpE N. <br /> SIGNED <br /> TITLE <br /> Abaf"---� <br /> W PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APF�LIC.ATION' ACCEPTED BY DATE — <br /> ADDITIONAL COMMENTS: G y <br /> PHASE II I�1 ECTION PHASE IN INSPECTION <br /> INSPECTION BY TE INSPECTION BY DATE <br /> i <br /> I E H 1426 Rev. 1-74 <br /> ;.. 1./7C nu 1 <br />