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( SAN JOAQUIN LOCAL <br /> FOF:.OFFICE USE• ALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> TRIS PERMIT EXPIRES 1 YEAR FROM DATE .ISSUED <br /> Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the Salt Joaquin Local health District for a permit to construct <br /> 1 <br /> and/or install the work herein described. This application is made in compliance with San Jonq u <br /> I County Ordinance No. 1862 and the Rules and Regulations of the San :Joaquin .Local Realth District <br /> JOB ADDRESS/LOCATION ` s� a <br /> c S.sa�s�T CENSUS TRACT <br /> Owner's Name } / <br /> Ph <br /> one <br /> f Address Q SG City . . U �i <br /> Contractor's Na - <br /> `` License y 2t <br /> TYPE DF WORK (Check): NEW WELL /? DEEPEN A � <br /> PUMP INSTALLATION / / RECONDITION �_ DESTRUCTION /_7PUMP REPAIR /? PUMP REPLACEMENT /? <br /> Other / / <br /> DISTANCE TO NEAREST: SLrTiC TANK <br /> SEWER LINES PTT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE -PIT <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL ' PUBLIC DOMESTICT <br /> HER <br /> ED SE WELL <br /> I INTENDUTYPE OF WELL <br /> � . Industrial CONSTRUCTION SPECIFICATIONS R <br /> Domestic Cable Tool Dia.. of Well Excavation <br /> /Private sz Drilled Dia, of Well Casing C <br /> Domestic/publics Driven of Casin Gauge <br /> X Irrigation Gravel Pack 8 g <br /> � Cathodic Protection RotaryDepth of Grout Seal <br /> Type of Grout <br /> Disposal ,Other , <br /> Geophysical Other Iaformaton <br /> -- <br /> Surface Seal Installed :B .. <br /> i PUMP I4STAI;LATIONt Contractor <br /> Type .of Pump , <br /> PUMP H.P. . -�.7 <br /> LX/ State Work Done, <br /> j PUMP .REPAIR: <br /> State Work Done <br /> 0ES,TRUCTION 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 ' 1-n <br /> Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> MELL'DRILLERS REPORT of the well and notify them before -putting.the well in use,. The above <br /> 1nforma'tion is true to the best of my 1k owle $e d belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING ANDA FINAL INs L IQ <br /> :SIGNED <br /> a%fes TITLE <br /> (DF�AW PLOT PLAN QN ERSE SIDE) <br /> 'PHASE I �� , FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> :ADDITIONAL COMMENTS: -DATE <br /> PHASE II GROUT INS CTION 'PHASE .III INAL INSPECTION <br /> _INSPECTION BY DATE INSPECTION BY —'' <br /> / ATE <br /> E H 1.426 Rev. 1-74 <br />