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. x - 'SAN LAQi LOCAL HEALTH DISTRICT � <br /> FOF OFFICE USE: 1601 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 theFSan'J6o quip 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''Rulessand Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT , <br /> Owner's Name rt - <br /> Phone <br /> Address7�f a — <br /> City _ <br /> Contractor's Name <br /> i ♦ !y.';,-- + License # L Phone <br /> TYPE. OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION /—// PUMP REPAIR / PUMP REPLACEMENT /_ <br /> Other — <br /> DI5TANCE 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 USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation _Z <br /> Domestic/private Drilled Dia. of Well Casing J �� <br /> Domestic/public' ' Driven Gauge of Casing f . <br /> Irrigation Gravel Pack Depth of Grout Seal (� <br /> Cathodic Protection Rotary Type of Grout ti <br /> Disposal Other `= ' 11 <br /> Other Information <br /> Geophysical Surface Seal Installed By. <br /> PUMP INSTALLATION: Contractor- <br /> Type <br /> ontractorType of Pump H.P. <br /> PUMP REPLACEMENT <br /> / / State Work Done 4� <br /> PUMP REPAIR: <br /> State Work Done � <br />)ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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 /> JELL 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 GROUTING AND INAL NSPECTION. <br /> iIGNED TITLE 4zl <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> �r V FOR DEPARTMENT USE ONLY s <br />'HASE I <br /> APPLICATION ACCEPTED BY DATE i <br /> d)DITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BYDATE <br /> y..:.-.tet . . <br /> E H 1426 _Rev. 1.-74 1 177 2M <br />