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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> f0—& OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ; <br /> Telephone: (209) 466--6781 _ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 75-- <br /> THIS <br /> sTHIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2 V 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 an gulations the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Niaie ' PhV <br /> one _ <br /> ` ! <br /> Address � � Cit � <br /> Contractox's Na �-�� /`'� License i(">374hone 2Zg�< Z'� <br /> TYPE OF WORK (Check) . NEW WELL /7 DEEPEN /—/ RECONDITION /-7 DESTRUCTION /-7 E <br /> PUMP INSTALLATION '/ / PUMP REPAIR'f PUMP REPLACEMENT / f <br /> Other /-7 <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 <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 /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BX: �� <br /> PUMP INSTALLATION: Contractor N <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT I / State Work Done <br /> PUMP .REPAIR: `" Siite Work Do - .SAA, <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure t <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District 1 <br /> and the State of California pertaining to or regulating well"construction. Within FIFTEEN DAYS f <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a C <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 INSPECTION. <br /> SIGNED TITLE <br /> (DRAWPLOT PLAN ON REVERSE SIDE <br /> FO DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE f � <br /> ADDITIONAL COMMENTS: . ' <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION � { <br /> INSPECTION BY DATE INSPECTION BY � /'' DATE <br /> s <br /> E H 1426 Rev. 1--74 r, h/7K 9M <br />