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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 �� ✓ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 /> rye <br /> JtB ADDRESS/LOCATION j"41/,r_ wAT 7,4,ANSUS TRACT <br /> Owner's Name / �. ,� Phone <br />'IF Address City <br /> Contractor's Name License # °"Phone E <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN/ / RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION/ / PUMP REPAIR / / PUMP REPLACEMENT /- <br />'E 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 l' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS s ■, <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of ,Well Casing <br /> Domestic,/public Driven- Gauge of Casing <br /> Irrigation ' Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> i Disposal Other Other Information <br /> �.Geophysical ` Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done �. <br /> PUMP .REPAIR: / / State Work Done, <br /> r <br /> DESTRUCTION OF WELL: Well t iameter a Approximate Depth <br /> Describe Material and Procedure <br /> l 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 /> linformati <br /> WELL DRILLERS REPORT of the 1 and notify them before putting the- well in use.. The above <br /> s true to the b s of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> 'PRIOR TO G T NG AND F NSPECTION. <br /> SIGNED TITLE _� � <br /> (DRAW PLOT PLAN ON REVERSE SIDE) j <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � <br /> APPLICATION ACCEPTED BY DATE � <br /> 1 ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY '�_ DATE <br /> rw ' r/'7! 2M <br /> E H 1426 Rev. 1-74 <br />