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SAN JOAQUIN xLa;CAL IMALTH- DISTRICT <br /> F(W.iC CE USE: 1601 E. Hazelton Ave. ,- Stockton, Calif. <br /> Telephone :. - ('209) 466w_6781_ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. f <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 Distract for a permit to construct <br /> and/or. install the work herein described. This application is made in com�liance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin`,Local Health District. <br /> I! : <br /> JOB ADDRESS/LOCATION cI Ca-;Sl D/ D_55&OZ CENSUS TRACT <br /> Owner's Name �, Phone - <br /> Address �" _ <br /> iG City <br /> Contractor's Name License # 029A,,71 Phone ' <br /> TYPE OF WORK (Check) : NEW WELL N DEEPEN '/—/ RECOND.ITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 C. <br /> Other /, / _ A <br /> t <br /> DISTANCE TO NEAREST: SEPTIC TANK -/- SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD &12/ CESSPOOL/SEEPAGE PIT _ OTHER 4 <br /> PROPERTYILINE - PRIVATE DOMESTIC WELL PUBLICDOMESTIC WELL, <br /> INTENDED USE TYPE OF WELL CONSTRUeT-.I.'ON�,SP_.ECI.FICATIONS - <br /> Industrial _. _ -Cable,"Tool �" � -Dia: `of ,Nell`Excavation • '` _ nr <br /> if Ze <br /> /Public r . . t -, <br /> Domestic .. rivate.- ., __.,Dr:i1=led_. .? -'�� .Dia.,'a,of We11. Casing '?r <br /> Domestic Driven Gauge of Casing <br /> Irrigation �/ Gravel Pack Depth ofr Grout Seal �� O <br /> Cathodic Protection �� Rotary( Type,'of Grout _ 9�1- � i <br /> � � <br /> Disposal 1 Other �`� :�,,,_. Other Information <br /> Geophysical ' Surf ace Seal- Installed By : <br /> PUMP INSTALLATION: Contractor , <br /> Type of Pump Nm\ H.P, . <br /> PUMP REPLACEMENT: / / State Work-Done <br /> PUMP .REPAIR: / / State Work Done <br /> — t <br />)ES•TRUCTION OF WELL: Well Dimeter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the SanrJoaquin 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 neF yell,_.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 />?RIOR TO GRO TING AND A F INSPEC'T'ION. <br /> SIGNED TITLE <br /> (PRAW PLOT PLAN REVERSE SIDE T _._,..._...... q <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / r� <br /> APPLICATION ACCEPTED BY , DATE t4l <br /> ADDITIONAL COMMENTS: 4 � ; <br /> PHASE II GROUT INSPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> J�� / i7 CPM <br /> E H 1426 Rev- 1-74I <br />