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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: / 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 4 Telephone : (209) ' 466-6781 <br /> t APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z_ yff? ID <br /> t <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -Z-z2L7 7 <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/LOCATION <br /> r� CENSUS TRACT <br /> .r <br /> Owner's Name p Phone � �� <br /> Address <br /> City <br /> Contractor's Name <br /> License #I Phone 3����7 <br /> TYPE OF WORK (Check) : NEW WELL/_/ DEEPEN '/_/ RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other �. <br /> 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 .r.J. i <br /> Industrial Cable Tool Dia., of Well ExcavationCA <br /> Domestic/private Drilled Dia. of Well Casing Q+ <br /> Domestic/public Driven Gauge of Casing _j <br /> Irrigation Gravel Pack Depth of Grout Seal y k <br /> Cathodic Protection Rotary TYp e'of Grout t <br /> Disposal Other Othet Information <br /> Geophysical Surface Seal' Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done Js13 # <br /> PUMP .REPAIR: <br /> State Work Done <br /> DESTRUCTION OF WELL:, Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I herebyagree to .cam 1 } <br /> g p y .with all Taws and regulations of the San Joaquin Local Health District <br /> and the State of''California• pertaining tofor regulating well '-construction. Within FIFTEEN DAYS <br />"after completion of -'q work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the�well and­notify'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 UTING AND A F NAL IN E,C ION. <br /> SIGNED t TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID , , <br /> FOR;DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY C -� DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II ROUT INSPECTION PHASE IIT/FINAL INSPECTION, <br /> INSPECTION BY DATE -7 BY t , DATE ! <br /> E H 1426 Rev. 1-74 , . 11Z72M <br />