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SAN JOAQUIN LOCAs. HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin LocalHealth <br /> District <br /> inrca compliance to constructth San o? n <br /> and/or install the work herein described. This pp , <br /> County Ordinance No. 1862 and the Rules and Regulations of the San' Joaquin Local Health District. <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> � <br /> G ®S_ _ L l 1. Phone <br /> Owner's Name �C•� ,# <br /> � City <br /> Address ' <br /> License 04044 Phone <br /> Contractor's Names-f <br /> i t <br /> DSTRU <br /> l _ 1 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN :/�/,1REPATRI/N// pUMPEREPLACEMENT <br /> �I ` <br /> PUMP INSTALLATION PUMP <br /> Other� / <br /> DISTANCE TTO .NEAREST: SEPTTCiTANK SEWER LINES PIT PRIVY OTHER <br /> SEWAGE�DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL CONSTRUCTION SP'— PUBLIC ECIFICATIONS <br /> INTENDED USE TYPE OF WELL <br /> Industrial ! Cable Tool Dia. of Well Excavation <br /> _ Drilled Dia. of Well Casing <br /> Domestic/private <br /> T7---7--`Dtiven "" ,. '" Gauge-,of..Casing 0 <br /> Domestic/public <br /> Depih .of Grout-Seal..- - <br /> Irrigation-.-, .- Te of Grout Q. <br /> Cathodic Protection ': r Rotary Other Information <br /> Disposal ''� •}- t .i ..Other Surface. Seal Installed B <br /> Ceophysical <, <br /> r ti <br /> PUMP INSTALLATION: Cont actor a H.P. . <br /> r x } Type` of <br /> IPump <br /> ', State WorkDone <br /> PUMP REPLACEMENT: <br /> PUMP .REPAIR: / / State Work Done <br /> � .. � Approximate Depth <br /> DES-TRUCTTON, OF WELL: Well Diameter ; <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 /> we11, I will furnish the San Joaquin Local Health District a <br /> after completion of my work on a new <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'GR UTING AN . INAL IN PE TON. TITLE - <br /> SIGNED 1; <br /> DRAW Ph T PIAN ON RE FRSE SIRE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> DATE <br /> r <br /> APPLICATION ACCEPTED BY <br /> b ADDITIONAL COMMENTS: PHASE /FIN �DAT <br /> ECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY — <br /> k INSPECTION BY 1. DATE <br /> 3/76 2 <br /> V is 1119A Rev_ '1-74 <br />