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f .. 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 /> ZL <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued F30,7 7 <br /> (Complete In Triplicate) <br /> Application is Aereby made to 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 Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> ZZ <br /> Address City <br /> Contractor's Name License �����0 9 Phone / <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other <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 "u <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing UI <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done p <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: 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 /> 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 GROUT G AND A FINAL INSPECTION. <br /> SIGNED TITLE i <br /> RAW PLOT PLAN ON REVERSE SIDE) Y . — <br /> . _ FOR DEPARTMENT USE ONLY._._,..,...___-•— - <br /> PHASE I q <br /> APPLICATION ACCEPTED BY (,✓ DATE <br /> ADDITIONAL COMMENTS: ! <br /> PHASE II GROUT INSPECTION PHASE /FINAf INSPECTWN <br /> INSPECTION BY DATE AllINSPECTION BY ATE <br /> E H 1426 Rev. 1-74 X77 2M 1 <br />