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iSAN JOA UIN LOC -- <br /> y FC}1$rOFFICE USE: ICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 11466-6781 <br /> y <br /> APPLICATION FOR WELL CON STRi3CTION OR PUMP PERMIT Permit No. ,7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued 2- <br /> (complete In Tr"iplicate) <br /> Application is hereby made to the San Joaquin Local .fiealth District for a permit to construct <br /> and/or install the work herein described. This application is made <br /> County Ordinance No. 1862 and the Rules and Regulati'ans of the San JoaquiLo alin complianceHealth San 3osquin <br /> with <br /> 6l8 ... fr�, .�, t ` District. <br /> JOB ADDRESS/LOGATI N <br /> f ! CENSUS TRACT <br /> Owner's Name <br /> S �r Phone <br /> Address ,�, .� <br /> City <br /> Contractor's Name {{ <br /> License V� Phone J <br /> Rh - <br /> TYPE OF WORK (Check): NEW WELL/ DEEPEN '/7 RECONDITION / DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT Er C)j_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKiM <br /> SEWER LINES I�. PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PITWE <br /> INTENDED USE ^ ` <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC LL '' <br /> TYPEOF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Di� of Well Excavation <br /> Domestic/private Drilled �� 147 <br /> Domestic/public Dia. of Well. Casing - p <br /> Driven Gauge of Casing <br /> Irrigationi�- <br /> Gravel Pack Depth of GroutSeal <br /> Cathodic Protection; Rotar � <br /> Disposal Oy T <br /> Other Other Information <br /> ype of Grout <br /> 1 <br /> Geophysical —•---- <br /> Surface Seal Installed B <br /> PUMP INSTALLATION: C <br /> - ontractor <br /> Type of Pump �M <br /> c H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: . ../? State.-Work Done - <br /> ESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth � <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 Satz 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 my knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO GROITTTMn AND A F INSPECTION. f <br /> SIGNED I <br /> I TITLE <br /> (DRAW PLOT PLAN ONIREVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION I� <br /> INSPECTION BYDATE PHASE FINAL INSPECTION <br /> - ! I - <br /> INSP9CTION- BY DATE _ -,?2- <br /> H <br /> ,?z--H 1426 Rev. 1-74 ; <br />