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�4 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. tc) <br /> 57 <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 / ' 3 /� CENSUS TRACT <br /> Owner's Name �� / , �[ 9,4 Phone <br /> Address City <br /> Contractor's Name <br /> LicensePhone <br /> TYPE OF WORK Check) ; ; <br /> ( NEW WELL /�EPEN RECONDITION /� DESTRUCTION /� <br /> PUMP INSTALLATION �UMp REPAIR / I PUMP REPLACEMENT /-7 <br /> Other / I -- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ! e PIT PRIVY <br /> SEWAGE DISPOSAL FIELD _e CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial moble Tool Dia. of Well Excavation <br /> Drilled <br /> =----Domestic/private Dia. of Well Casing <br /> Domestic/publicDriven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal i <br /> .� <br /> Cathodic Protection Rotary Type of Grout _ <br /> Disposal Other Other Information �' a e 'er` <br /> Geophysical � � Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pumpr.� n <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Done i <br /> DESTRUCTION OF WELL; Well Diameter <br /> Describe Material and Procedure Approximate 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 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 GROU IMGD A FINAL INSPE <br /> SIGNED <br /> TITLE <br /> ' . (DRAW PL T PLAN ON REVERSE SIDE) . <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY , ,P DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY PHASE III/FINAL INSPECTION <br /> r � DATE - INSPECTION BY <br /> -- ��•�� DATE z.-z�' i <br /> E H 1426 Rev. 1-74 376 2M <br />