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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. .Hazelton Ave. , Stockton, Calif. <br /> Telephone (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. J:;5 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued <br /> Application is hereby made to the San(ComJoaquin Lolete In calrHealth District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaqu: <br /> :.ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District <br /> TOB ADDRESS/LOCATION S �/ <br /> CENSUS TRACT <br /> )vner's Name <br /> Phone l <br /> Lddress <br /> City <br /> contractor's Name / e�Z <br /> icense # . . O Phan <br /> YPE OF WORK (Check): NEW WELL / DEEPEN /� gEC01,JDITiON /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR -7 PUMP REPLACEMENT /-j <br /> Other <br /> ISTANCE TO NEAREST: SEPTIC TANK <br /> 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 <br /> DomesticDomes /private Drilled Dia. ,of Well Casing v <br /> /public Driven Gauge of Casing <br /> Irrigation GG avel Pack Depth of Grout Seal <br /> Cathodic Protection /„/kotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical "'----- <br /> Surface Seal Installed B <br /> MP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> MP REPLACEMENT: / / State Work Done <br /> MP •REPAIR: / / State Work Done <br /> QTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate -Depth <br /> iereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> I the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> :er completion of my stork on a new well, I will furnish the San Joaquin Local Health District <br /> .L DRILLERS REPORT of the well and notify them before putting the -well in use.... The above <br /> formation is true to the•best of my.knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> OR TO GtOUTINC, ANW FINAL. NS CTIO <br /> :NED .� TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> SE I FOR DEPARTMENT USE ONLY <br /> LICATION ACCEPTED BY <br /> ITIONAL COMMENTS: /y DATE o?� <br /> PHASE II GROUT INSPECTION N <br /> PHASE III/FINAL INSPECTIO <br /> PECTION BY DATE ` INSPECTION BY <br /> E'H 1426 Rev. 1--74 <br />