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F SAN JOAQUIN LOCAL 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 /> + , <br /> �� .• THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 72-l14<y� <br /> Date Issued y y=7J <br /> (Complete In Triplicate) b SS c3Zt1-p� <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 J a uin Local Health District. <br /> /!s` ,w ez <br /> JOB ADDRESS/ ,,� r* r- ' a! NSUS TRACT <br /> Owner's Name <br /> �. _._ ,.. Phone <br /> Address City <br /> Contractor's Name I License 17 Phone i <br /> �i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPENf/_/ RECONDITION / / DESTRUCTION /'7 <br /> S a <br /> PUMP INSTALLATION ' PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br />.DISTANCE TO NEAREST . .SEPTIC TANK SEWER LINES- _ZtvIPIT PRIVY <br /> SEWAGE DTSP SAL F ELD CESSPOOL SEEPAGE PIT OTHER <br /> PROPERTY LINE��RIVATE DOMESTIC WELf440ts PUBLIC DOMESTIC WELL c <br /> INTENDED USE TYPE OF WELL _ r CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/privates Y. Drilled Dia. of Well Casing. 'Y._. _ <br /> Domestic/public Driven Gauge of Casing Ar'/_ <br /> Irrigation Gravel Pack Depth of Grout Seal loo 4-- <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal T 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 �F <br /> PUMP .REPAIR: <br /> State Work Dorie <br /> DESTRUCTION 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 a belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTI <br /> SIGNED LE <br /> D L ON REVERSE SIDE) <br /> i> OR PARTMENT USE ONLY ; <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II 2E96T INSIIECTION PHASE I I/FINAL INSPECT O.N i <br /> INSPECTION BY DATE INSPECTION BY ,✓ DATE <br /> E H 1426 Rev. 1.-74 ' 3/76 2M J <br />