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SAN JOAQUIN LOCAL- HEALTH DISTRICT <br /> FOR 0 FICE USE:. 1601 E. Hazelton.Ave'. , Stockton, Calif. <br /> Telephone: (209) 466-6781 p D <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. D 1 <br /> Y <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made <br /> 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 Rule's and Regulations of the San Joaquin Local Health District. <br /> i CENSUS TRACT <br /> JOB ADDRESS/LOCATION !'I <br /> Owner's. Name i . - Phone <br /> ' City t..+ <br /> Address <br /> ` l License # �.,�yc{`P one Y'2626 <br /> Contractor's Name - <br /> TYPE OF WORK (Check) : ;ANEW WELL -/ / DEEPEN /�/ !• RECONDITION / / DESTRUCTION <br /> .PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT 17 n <br /> Other <br /> .i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT s. OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS I ; <br /> Industrial Cable Tool Dia. of Well Excavation 11 <br /> �` Dia. of Well Casing <br /> 1C Domestic/private: Drilled <br /> Domestic/public ii Driven Gauge of Casing <br /> i <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout C <br /> Disposal Other Other Information <br /> Geophysical . iI Surface Seal Installed B !� <br /> Z <br /> PUMP INSTALLATION: IlContractor <br /> Type of Pump H.P. / <br /> PUMP REPLACEMENT: / / State Work Done <br /> ..State Work Done <br /> PUMP ,.REPAIR-, y/i <br /> iDES;TRUCTION OF WELL: d 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 /> Within FIFTEEN DAYS <br /> and the State of 'California pertaining to or regulating well ''construction. <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 my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INU.NT <br /> SIGNED ` LOT - TITLE r <br /> �`, ; (DRAW PLAN ONVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE �07 <br /> APPLICATION ACCEPTED By . ' <br /> ADDITIONAL COMMENTS: 9. PHASE III/FINAL INSPECTION <br /> PHASE III-GROUT INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br />