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w <br /> �V S TOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OF�ICE USE: 1601 r.. Hazelton Ave. , Stockton, Caliz . <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 /> County Ordinance No. 1862 and the Rules hand Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION S�,z y� o G+�, % ty :{<ar / �Q t7�,� ..t; �l�� ,gENSUS TRACT <br /> Owner's Name Q o�I G I�� uj r(�r�.� Phone <br /> Address 0, .z a! fit,), /f1' �t�!'��F'�. City <br /> z <br /> Contractor's NaLicense Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR /k'/_PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE 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: <br /> PUMP INSTALLATION: Contractor �'~ • f°/ �� '� ,./ <br /> Type of Pump r H.P. .r— <br /> PUMP REPLACEMENT: / / State Work Done , <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 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 a <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 myknowledge. and belief. I WILL CALL FOR A GROUT INSPECTI N <br /> PRIOR TO CT G OUTING AND A FINAL INSP N <br /> SIGNED /- TITLE {�✓a r J <br /> W PL PLAN ON E7tSE SIDE) <br /> FO DEPARTMENT,,USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPDATE <br /> T <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY Lie, DATE 7G <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />