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SAN JOAQUIN WAL R�ALTH.DISTRICT <br /> USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209)' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7.Sr-3%r�L✓ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete in Triplicate) <br /> lication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> / nd/or install the work herein described. This application is made in compliance with San Joaquini <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner°s Name Phone jaa <br /> Address { City _ <br /> Contractor Name ,Z _ License 4� t'1a�ay Phone d}_�j,d <br /> 7� <br /> TYPE OF WORK (Check): NEW WELL /?f DEEPEN/7 RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR /—/ PUMP REPLACEMENT 17 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 6* 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 _ Cable Tool t �. ,�. Dia.of Well Excavation 'l <br /> Domestic/private - Drilled = �- �� <br /> Dia: of Well rCasing-� <br /> Domestic/pubic : +_, Driven ,4 . .,Gauge of Casing &Ld� �( � <br /> Irrigation - Gravel-Pick= Depth of Grout Seal �. z <br /> Cathodic Protection -` Rotaryr=� 's'�-'6 Type of Grout <br /> Disposal . Other- a!", Other (Information <br /> Geophysical u Surface Seal,Installed--By., <br /> PUMP INSTALLATION: . , , Contractor <br /> i Type -of PumoI ; H.P. <br /> PUMP REPLACEMENT: %// State Work Done <br /> PUMP-'REPAIR:.... =�State Work�Done ` <br /> ES�TRUCTION OF WiLL': `'- 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 <br /> WELL DRILLERS REPORT of the well and notify theta before puttingthe 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 <br /> DRAW PLOT PLAN ON REVERSE S1DE <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYr�( <br /> DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE FIN' INSPECTION <br /> INSPECTION By' DATE INSPECTION BY DATE j <br /> t E H 1426 Rev. 1-74 <br />