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W1601 <br /> SAN JOAQUIN LOCAL HEAL DISTRICT <br /> FOE MFFIC US <br /> 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 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 GL#P0 C, ON) ®4ep.r,,k, 'Ra <br /> CENSUS TRACT <br /> Owner's Name f <br /> Address <br /> � Phone . <br /> 111�,1111. 11110 <br /> City <br /> Contractor's NameVoo <br /> License #1±t2A--Phone �. <br /> TYPE OF WORK (Check): NEW WELL '/? DEEPEN/? RECONDITION /? DESTRUCTION f7 <br /> PUMP INSTALLATION/ / PUMP REPAIR / PUMP REPLACEMENT f-]" <br /> Other -- <br /> DISTANCE ro NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD <br /> PROPER _ CESSPOOL/SEEPAGE PIT <br /> INTE }} <br /> TY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTICTWELL 1 <br /> NDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> industrial <br /> Domesti _ Cable Tool Dia. of Well Excavation <br /> c/private Drilled Dia. of Well Casing <br /> Domestic/public Driven <br /> Irrigation Gauge of Casing <br />-rte Gravel Pack Depth of Grout Seal { <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ' <br /> Geophysical _ - Surface Seal Installed B •� <br /> PUMP INSTALLATION: } Contractor p <br /> Type of Pump � "~ <br /> H.P. <br />'UMP REPLACEMENT: <br /> Ll State Work Dane � <br />'UMP (REPAIR: State Work Done 4-5:4,*tre Vo AVF ,,123 <br /> LES,TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br />.nd the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> ter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br />'ELL DRILLERS REPORT of the well and notify them before putting.the..well. in.use.... <br /> reformation is true to- the•best �of m The above <br /> 1IQR TO GROUTING ANDA 'iNAL INSPECTIO led a belief. I WILL CALi. FQR A GROUT INSPECTION <br /> IGNED <br /> TLE <br /> (D P AN ON RE RSE SID'E)- " . <br /> RASE I a F DEPARTMENT USE ONLY <br /> pPLICATION ACCEPTED BY <br /> DDITIONAL COMMENTS: DATE <br /> PHASE IT GROUT INSPECTION PHASE III ]FINAL INSPECTION <br /> 1SPECTION BY DATE _ INSPECTION BY <br /> DATE <br /> E H 1426 Rev. 1-74 <br />