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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOROFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (201) 466-6781 { <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�/ 3/6,�J <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued 7-1�'-741 <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 phe Rules and Regulation of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT f <br /> f / <br /> Owner's Name • :. r. :- - Ph'%"one <br /> Address J1 ,,.. Cit �r- z-� <br /> Contractor's Name P.f = .� �- / License ��� 7.3 7-3 Phone 6 IL <br /> TYPE -OF-WORK- (Check) : NEW- WELL DEEPEN / RECONDITION /-T DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR &7PUMP REPLACEMENT /-7 <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-- <br /> INTENDED <br /> ELT.INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> 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 <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of of Pump c _..: ,, H.P. <br /> PUMP REPLACEMENT: / / State Work Done ^r <br /> PUMP .REPAIR: State Work Done .f � - <br /> ES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all lawns 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 GROUTIIG D A FINAL INSPECTION, Z-0. <br /> SIGNED TITLE -r <br /> (DRAW PLOT PLAN ON REVERSE SIDE) rl <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 4W,. DATE D, <br /> I E H 1426 Rev. 1-74 1-74 2M <br />