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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ! FOE 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 9- <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 /> k� County Ordinance No. 1862-.and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> 3_Owner's Name Phone <br /> A <br /> Address to IN /.L�XsI A�.f4� _ --- City jrjZ;0 <br /> Contractor's Name License # L Phone c5 <br /> TYPE OF WORK (Check) : NEW WELL DE ..^y LL�� , `^_ <br /> _ EPEN /� RECONDITION /� �DESTRUCTION�/=T � <br /> t PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT / <br /> # Other <br /> E <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES . PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL_ ,r PUBLIC DOMESTIC WELL <br /> 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 /> F Irrigation Gravel Pack Depth. of-Grout. Seal \_ <br /> Cathodic Protection Rotary Type of Grout i <br /> E f Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> f PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done �1l <br /> 'PUMP,-REPAIR:-- -Work-Done- <br /> DESTRUCTION OF WELL: Well Diameter.. Approximate Depth <br /> Describe Material and Procedure <br /> I, <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 <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 GROUTING AND A FINAL INSPECTION, <br /> SIGNED TITLE <br /> W: O��t <br /> PLAN SE SIDE <br /> D1 <br /> ,T FOR DEPARTMENT USE ONLY <br /> PHASE I . <br /> APPLICATION ACCEPTED BYLZ <br /> - - DATE /�'" Z Z <br /> ADDITIONAL -COMMENTS: <br /> } 4 PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION . <br /> INSPECTION BY DATE INSPECTION BY DATE 9 -1 3'7T <br /> V76 <br /> E H 1426 Rev. 1-74 <br />