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SAN JOAQUIN LOCAL HEALTH DISTRICTFOr OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br />Telephone: (209) 466-6781. <br />APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.aoljo <br />THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 17 <br />Complete In. Triplicate) <br />Application is hereby made to the San Joaquin Local Health District for a permit to constructand/or install the work herein: described. This application is trade in compliance with San JoaquinCountyOrdinanceNo. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br />JOB ADDRESS/LOCATION CENSUS TRACT <br />Owner's Name Phone <br />Address _ <br />2-Ap CityContractor's Naim:Led License # lS" Phone <br />TYPE OF WORK (Check): NEW WELL/7 DEEPEN '/_`7 RECONDITION / j7DESTRUCTIONf <br />PUMP INSTALLATION PUMP REPAIR/7J PUMP REPLACEMENT /7Other / / <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br />SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br />INT <br />PROPERTY LINE -- PRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELLINTENDEDUSETYPEOFWELLCONSTRUCTIONSPECIFICATIONSIndustrialCableToolDia. of Well ExcavationDomestic/private Drilled Dia. of Well CasingDomestic/public Driven Gauge of CasingIrrigationGravelPackDepthof .Grout Seal <br />Cathodic Protection Rotary Type of Grout <br />Disposal Other Other Information <br />Geophysical Surface Seal Installed-B 4 <br />PUMP INSTALLATION: Contractor <br />Type of Pump H.P. i <br />IPUMPREPLACEMENTStateWorkDone <br />PUMP ,REPAIR: State Work Done <br />DESTRUCTION OF WELL: Well Diameter Approximate Depth <br />Describe Material and Procedure <br />I hereby agree to comply with all laws and regulations of the San Joaquin Local Health DistrictandtheStateofCaliforniapertainingtoorregulatingwell"construction. Within FIFTEEN DAYSaftercompletionofmyworkonanewwell, I will furnish the San Joaquin Local Health District a SWELLDRILLERSREPORTofthewellandnotifythembeforeputtingthe -well in.use.. . The aboveinformatiotruetothe.. est .of. my knowledge and belief. I WILL CALL FOR A GROUT INSPECTIONPRIORTOOUTIANDAIIpE <br />SIGNED TITLE/ <br />DRAW PLOT PLAN ON REVERSE SIDE I <br />PHASE I <br />FOR DEPARTMENT USE ONLY <br />APPLICATION ACCEPTED BY DATE Z -2S 7ADDITIONALCOMMENTS: <br />PHASE II GR,0UT INSPECTION PHASE III FINAL INSPECTIONINSPECTIONBYDATEINSPECTIONBYDATE z <br />E H 1426 Rev. 1-74 h/75 J