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eS n SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORT FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> �f APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Ts <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 /> JOB ADDRESS/LOCATION. k) . i4m CENSUS TRACT <br /> &mer I s Name <br /> .. Phone •� <br /> Address <br /> City <br /> Contractor's Name )40/j , <br /> License # /23 Phone X " 4 <br /> Or <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN '/_7 "RECONDITION /_7 DESTRUCTION 1-7 <br /> PUMP INSTALLATION /_1 PUMP REPAIR / PUMP REPLACEMENT 1 <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 WELL Q <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ Industrial Cable Tool Dia, of Well Excavation <br /> 4_ 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 4 <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 42 <br /> ' Type of Pump H.P. <br /> r - <br /> PUMP REPLACEMENT: / ./ State Work Done <br /> PUMP !REPAIR: State Work Done' <br /> ES;TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> f <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 r <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 knowl ---an belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPE <br /> SIGNED <br /> I T L E <br /> PL PLAN ON FRSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ye <br /> PHASE II GROUT ftSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY � DATE INSPECTION BY DATE <br /> 3 E H 1426 Rev. 1-74 ,��� �,� • . <br />