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I FOA OFFICE USE• SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> bz 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 1466-6781 <br /> s <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued 2- <br /> S <br /> (Complete In Triplicate) <br /> j 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 Regulatns of she San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIdN A�rR J`X <'l <br /> CENSUS TRACT 0S8- p-7c)--f(9 <br /> Owner's Name / I Phone 3lo f'G/ <br /> Address ���,� �L�[-rL� L <br /> City p B/ <br /> Contractor's Name �f��� d �� � . Licensee Phon I <br /> TYPE OF WORK (Check) : NEW WELL /7-T-DEEPEN /7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION —/ / PUMP REPAIR / / PUW REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKS <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD - CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL T PUBLIC DOMESTIC WELL I <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECYFICATIONS <br /> Industrial Cable Tool Di; , of Well Excavation <br /> Domestic/private Drilled � ! fi <br /> Dia. of Well Casing /O <br /> Domestic/public Driven Gauge of Casing / 7 <br /> Irrigation {V� <br /> Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary T ^C <br /> ype of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump tl H.P. <br /> c _ <br /> PUMP REPLACEMENT: / / State Work Done I� <br /> PUMP '.REPAIR: - /7 State Work Done <br /> ES•TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District7 <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, <br /> PRIOR TO G T G AND A F INSPECTION. I WILL CALL FOR A GROUT INSPECTION <br /> SIGNED TITLE %T 1 <br /> (DRAW PLOT PLAN ONIREVERSE SIDE) I <br /> PHASE I FOR DEPARTMENT USE ONLY I <br /> APPLICATION ACCEPTED BY fj� SI <br /> ADDITIONAL COMMENTS: xn q DATE <br /> PHASE II GROUT INSPECTION Q PHASE III FINAL INSPECTION <br /> SPECTION BY DATE INSPECTION BY - - DATE /-,7a-7G <br /> `�g H 1426 Rev. 1-74 <br />