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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 <br /> (Complete In Triplicate) <br /> 1pplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> ind/or install the work herein described. This application is made in compliance with San JoaquJ <br /> :ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District, <br /> SOB ADDRESS/LOCATION 2 fa CENSUS TRACT <br /> rwner's Name Phone IE <br /> Adress City <br /> ontractor'a Name Uel License # 80/ Phone <br /> : <br /> YPE OF WORK (Check): NEW WELL/? DEEPEN '/_7 RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION &., PUMP REPAIR/-7—PUMP REPLACEMENT 17 <br /> Other /_7 <br /> ISTANCE 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 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of .Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By! O c.c,71,e41-- <br /> JMP INSTALLATION: Contractor <br /> Type of Pump �'7� H.P. <br /> , v <br /> TMP REPLACEMENT: / J State Work Done <br /> JMP�R: I / State Work Done <br /> ,SjRUCTION OF WELL: Well Diameter Approximate Depth <br /> ~� Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> td the State of California pertaining to or regulating well'construction. Within FIFTEEN DAYS <br /> `ter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> :LL DRILLERS REPORT of the well and notify them before putting the well in use.. . The above <br /> tformatio true to the jkest of, my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> IOR TO kOUTINP AND A FI PE <br /> GNED TITLE/ <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> ASE I <br /> 'PLICATION ACCEPTED BY DATE +�5 -2,,S� 7 <br /> DITIONAL COMMENTS: <br /> PHASE II G UT INSPECTION PHASE III FINAL INSPECTION <br /> SPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br />