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�i10, SAN JOAQUIN. LOCAL HEALTH, DISTRICT <br /> 08 <br /> FrOFFICE USE: x.601 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'Ithe San Joaquin-Local Health District for a permit to construct <br /> and/or i.nstall.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 ' .]. , . � 12 1 CENSUS TRACT <br /> Owner Is Name (� <br /> ' Phoned <br /> Address t.�' v '� City BSc ial e <br /> Contractor°s Name ;_i c` •� '� �}_„----- License # 7c101 Phone 0 7 <br /> _ S55 <br /> ' F <br /> . � ..,:y._ _ - -iii •..� •��� _ - -__ - _ ... �- - _ -. .�� ...- _ <br /> 1 J <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN -/ RECONDITION /? DESTRUCTION <br /> L:�PUMP INSTALLATION / / PUMP REPAIR PUMP REPLAC NT� /_7 <br /> Other 07 S&� <br /> DISTANCE TO NEAREST: SEPTIC TANK w SEWER LINES PI'S PRIVY <br /> `SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT r OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC •WELL PUBLIC DOMESTIC WELL -•� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i Cable TOOK. ” Dia. of Well Excavation, <br /> Domestic/privates i Drilled Dia, of Well Casing i <br /> Domestic/public i. Driven Gaugemof" Casing <br /> Irrigation j Gravel Pack Depth of Grout Seal <br /> Cathodic Protection d Rotary —Type of Grout <br /> Disposal I Other.w ,._Other_Information, _ <br /> Geophysical Surface Seal Installed By: ! <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State <br /> State Work Dome <br /> r <br /> Pt1MP REPATR:'�""""`-�'� - State Wok Don / - <br /> �y I <br /> PESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply withlall laws and regulations of the San ,Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. lWithin FIFTEEN DAYS j <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-user. The above <br /> information is true to the-beat of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO ING AND FIN INSPECTION. <br /> SIGNED i TITLE J <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 44 <br /> DATE <br /> ADDITIONAL COMMENTS: 1 <br /> PHASE TI GROUT INSPECTION PHASY, II F INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -25 <br /> t E H 1426 Rev. 1-74 i 1-74 2M <br />