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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0-9,6-F-R'61 1601 E. Hazelton Ave. , Stockton, Calif. � t <br /> Telephone : (209) `466-6781. <br /> u APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. I3 <br /> a <br /> THIS PERMIT EXPIRES 1 YEAR FROM -DATE ISSUED Date Issued j a <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. Joaqui.n. Local Health District. <br /> JOB ADDRESS/LOCATION , CENSUS TRACT <br /> Owner's Name Phone � () [ <br /> E <br /> AGityddress �� _ - - -.--.-- <br /> Contractor's Name License It_�y Phone (rf`/' .3a <br /> TYPE OF WORK (Chek) : NEW WEL / DEEPEN / / RECONDITION /_� DESTRUCTION <br /> -"`'"—PUMP I pN'STELATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> �' Other 1 / �`-"`- <br /> DISTANCE TO NEAREST: SEPTIC TANK 4,0' SEWER LINES PIT PRIVY , {1 <br /> �. SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER T.1_ <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ji Cable Tool Dia. of Well Excavation ' <br /> { i , <br /> Domestic/private Drilled Dia. of Well Casing 4 <br /> Domestic/public � Ift Driven Gauge of Casing <br /> Irrigation , Gravel Pack Depth of Grout eal D <br /> Cathodic Protection4- Rotary Type of Grout ('nir,..��.. <br /> Disposal `- .+.� Other Other Information <br /> Geophysical '" Surface Seal Installed BV: <br /> 4 i y <br /> PUMP INSTALLATION' 'Contractor H P <br /> �-Type of Pump .+ H.P. <br /> r <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done 1 <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 Distr et ` <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAY-S-- <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 and belief. I WILL .CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPE TION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SID <br /> WINVECTION <br /> FOR DEPARTMENT USE ONLY <br /> PHASE IAPPLICATION ACCEPTED BYDATEADDITIONAL COMMENTS: <br /> PHASE II PHASE III/FINAL INSPECTION <br /> '* INSPECTION BY 'DATE INSPECTION BY DATE <br /> l � <br /> n/7.7 <br /> _ <br /> •• <br /> '—T- H 1426 Rev`,i--74 _ - <br />