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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFE OFFICE USE• <br /> 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209)' 466-6781 <br /> ' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. `7 7_ 3 6 df° <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 77. <br /> (Complete In Triplicate) <br /> Application is Aereby 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. 2862 and the Rules and Regulations a€ the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ;�Jt7CENSUS TRACT <br /> Owner's Name � <br /> Phone ` { <br /> Address <br /> City '_ ' <br /> Contractor's Name 5-;�)7 License &C.JRC Phone <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN f_1 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> w� k <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY s <br /> SEWAGE DISPOSAL FIELD CESSPOOL/.SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL—� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONSMEMM <br /> { <br /> Industrial Cable- Tool— Dia.. of Well .Excavation � <br /> Domestic/private Drilled.- Dia. of Well Casing �k <br /> Domestic/public Driven" Gauge of Casing <br /> Irrigation ; Gravel Pack + Depth of Grout Seal <br /> Cathodic Protection`Rotary-, <br /> Disposal Type: of Grout <br /> 10ther _ _ Other Information <br /> Geophysical Surface Seal Installed By: <br /> c <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: <br /> / / State; Work Done 7 .' <br /> i <br /> PUMP -.REPAIR: / / State`Work Done <br /> DESTRUCTION OF WELL: Well Diameter; Approximate Depth <br /> Describe Material and Procedure <br /> i <br /> I hereby agree"to comply'with all laws --and- regulati-ons~of-the-San~Joaquin- Local. -Health- istrict <br /> and the.State of °California pertainingj or^regulating well •'construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin-Locai HeiZti�District a <br /> WELL DRILLERS REPORT of the well aid°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 G OUTING AND AIFINAL INSPECTION. <br /> SIGNED r TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I . <br /> FOR DEPARTMENT USE ONLY <br /> s <br /> APPLICATION ACCEPTED BY <br /> DATEV_ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS I/FIN INSPECTION <br /> INSPECTION BY DATE INSPECTIONBY DATE ', `2 <br /> E H ].426 Rev. 1-74 - <br />