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r! SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO&.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> b APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. S-G/ j <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued�� <br /> (Complete In Triplicate) <br /> --- <br /> Application is hereby made to the San Joaquin Local Health District for a permit <br /> and/or install the work herein described. This to construct application is made in compliance with San Joaquins' <br /> County Ordinance No, 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> I JOB ADDRESS/LOCATION r g <br /> ow. CENSUS ,TRACT <br /> Owner's Name <br /> Phony/ r <br /> Address L <br /> C tim <br /> Contractor's,•Name ,-;6 <br /> License # Phone <br /> TYPE OF WORK (Check): NEW WELL / ; DEEPEN -/ / RECONDITION /7 DESTRUCTION /-j <br /> PUMP INSTALLATION / L `'pUNp REPAIR I / FUMP REPLACEMENTI? <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 <br /> INTENDED USE TYPE OF WELL WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavation <br /> _,r-Domestic/private Y Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protectio;i Rotary Type of Grout <br /> Disposal Other Other Information <br /> GeophysicalSurface Seal Installed BX: <br /> PUMP INSTALLATION: Contractor " <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: j/ / State Work Done <br /> PUMP '.REPAIR; /-7 State Work Done <br /> ES•TRUCTION OF WELL: Well Diameter - �.. <br /> Describe Material and Procedure lApproximate Depth <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 puttingthewell in use.. The above <br /> information is true to the best of. my knowledge and belief. <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. I WILL CALL FOR A GROUT INSPECTION <br /> SIGNED . .. '_ -" �t- a.t-�.��•' ,�'-'~.."- TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APP <br /> LIGATION ACCEPTED BY <br /> ADDITIONAL COMMENTS.: `' DATE <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> DATE <br /> E H 1426 Rev.. 1-74 <br /> i-76 9M <br />