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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. <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 ' I <br /> and/or install the work hereindescribed. This application is made in compliance with San Joaquin , <br /> County Ordinance No. 1862 and the Rules and Regulations 6f the San Joaquin Local Health District. <br /> f <br /> JOB 'ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> Address C O �, 1Q RCityC��- <br /> Contractor's Name <br /> License 4� �CfL!� hone --0 <br /> i <br /> TYPE OF WORD (Check) : NEW WELL f DEEPEN. / RECONDITION_/ / DESTRUCTION /? i <br /> PUMP INSTALLATION /�1 PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> 3 Other <br /> DISTANCE TO NEAREST: .SEPTIC TAN WER LINES 4--RIT PRIVY <br /> �* SEWAGE DISPOSAL FIELD _%� ESSPOOL/SEEPAGE'PIT OTHER <br /> 4.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 /> �mestic/private Drilled Dia./of Well Casing c � <br /> Domestic/public Driven Gauge of Casing--:- _. � <br /> f� Irrigation Gravel Pack Depth of Grout Sea <br /> C ttiodi Prate tio� KO—Lrrazt <br /> _Disposal Other ather�-Information <br /> . .Geophysical .. ,Surf Seal Insta ed <br /> PUMP-INSTALLATION: Contractor <br /> H.P <br /> Type of Pump a �• <br /> State Work ;Done r <br /> PUMP REPLACEMENT-. / / r <br /> PUMP .REPAIR: / / State Work Done <br /> NTION OF WELL: Well Diameter J V GAJ [ APpr ximate pth <br /> DES•TRUC _ <br /> Describe Material anA7 Procedure <br /> dr .. <br /> I hereby agree to comply with all laws and'regulationsof 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:furnis`h 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 /> info tion is true to th s my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR T OUTING AND A F N S <br /> SIGNED .....TITLE _- Q <br /> -- <br /> ' D W;PIa'T PLAN ON REV'E'RSE SIDE) f <br /> DEPART NT USE ONLY 1 <br /> PHASE <br /> ' APPLICATION ACCEP ' ifA L/`N6%( DATE '� -/. <br /> ADDITIONAL COMMENTS: 4 # <br /> PHA.M IT. G T NSPECTIO 1. PHA II INAL INSPECTION <br /> INSPECTION BY ATE 2 ,.�1JNSPECTION BY DATE a <br /> s3 ' <br /> 3/76 2M <br /> E H 1426`, Rev. .1-74 <br />