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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'Ithe 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 Na. 1862 andathe: Rules and Regulations of. the San—Joaquin—Local Health District. <br /> JOB ADDRESS/LOCATION / .qJ CENSUS TRACT'W <br /> . <br /> Owner's Name Phone <br /> Address CitySSC <br /> Contractor's Name License #� 9a'D Phone <br /> - i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/—/ RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION /. / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other /i / <br /> _r <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 1 Drilled. Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation ,1 Gravel Pack Depth of Grout Seal Q <br /> Cathodic Protection Rotary s Type of Grout <br /> Disposal = Other Other Information �+ <br /> G`eo h sical ,�.. <br /> p Y Surface Seal Installed By ; <br /> PUMP INSTALLATION: Contractor a <br /> i <br /> Type of Pump H.P. " <br /> PUMP REPLACEMENT: ` J / State Work Done <br /> PUMP REPAIR: State Work Done C1 ' <br /> .., f <br /> DES-TRUCTION OF WELL: Wel!1-Diameter Approximate Depth <br /> Describe Material and Procedure <br /> t� <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 my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROW, NG AND A F AL IN PECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ��` � 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INS4rECTION PHASE III/FFNAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 4) ( DATE 112 �-a <br /> 6177 <br /> E H 1426 RevY�l-74 <br /> . 2M <br />