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F'OF"OFFICI E USE: SAN JOAQUIN LOCAL, HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 2 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT. EXPIRES 1 YEAR FROM DATE ISSUEDData Issued f-,;26-71(Complete In Triplicate) 1""—" <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 ismade in compliance with San Joaquin <br /> County' Ordinance, No., 1862 and the Rules and Regulations of the San Joaquin Local Health Distract. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address. <br /> 4 City . . <br /> Contractor's Name .-- License #� // <br /> � Phone <br />�^ TYPE OF WORK (Check) : - -` -� <br /> ( NEW WELL / / DEEPEN _/ RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> 3 <br /> Other :,'/ / . . ._ .. <br /> DISTANCE TO NEAREST: SEPTIC TANK s _r SEWER LINES -� PIT PRIVY <br /> SEWAGE DISPFIELD _ CESSPOOL/SEEPAGE PIT �1- OTHER �— <br /> PROPERTY LIN RIVATE.-DOMESTIC WELL�C� PUBLIC <br /> INDOMESTIC WELL, <br /> TENDED USE TYPE OF WELL � t, . , ACONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool �yf Dia, of Well Excavation <br /> Domestic/private I Drilled Dia.jof Well Casing <br /> Domestic/public t Driven Gauge of Casing ` <br /> Irrigation xj Gravel Pack Depth of Grout Sea! ze.ZZ <br /> CatIC68ic Protection <br /> I Rotary Type of Grout <br /> Disposal 1 Other 'Other Information <br /> Geophysical 17 Surface Seal Installed By: <br /> YZ <br /> PUMP INSTALLATION; Contractor r�1 � • <br /> Type ofPump <br /> H.P. <br /> PUMP REPLACEMENT: <br /> / / State Work`Done <br />'PUMP'.REPAIR:_ "� '"�/_ ./_ _.Sta,te Work <br /> -Done- <br /> 14 <br /> D <br /> .one___-- <br /> DES-TRUCTION OF WELL::— a We-1-1-Diameter <br /> Describe Material and Procedure Approximate Depth ' <br /> C <br /> I hereby agree to comply with all laws and regulations of the an Joaquin Local Health District <br /> and the State of -California pertaining to or regulating well "construction. Within FIFTEEN DAYS <br /> afterrcompletion 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, .thet my n ledge and belief. I WILL CALL FOR A GROUT INSPECTION ; <br /> PRIOR TO AN A FI I 91E <br /> SIGNED <br /> TITLE <br /> 7. ( W PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY = DATE �~ � -]� <br /> ADDITIONAL COMMENTS: I <br /> PHASE II GROUT INSPECTION <br /> � :. PHASE /FTN INSPECTION , <br /> INSPECTIONIBY,. _ DATE - INSPECTION- BY DATE <br /> - <br />,- "�- <br /> - �/ <br /> -•�E _H�l426 � Rev. ]-74 � . Z t�� <br />