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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FoT:OFFICE USE; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: % <br /> p {209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2,6- 9-V 3p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2,a-4 -79 <br /> (Complete In Triplicate) <br /> Application is hereby 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 u sand i sof th a Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone ' <br /> Address ,/ City <br /> Contractor's Name ' License O bT®?Phone <br /> TYPE OF WORK (Check): . NEW WELL '/-7 DEEPEN -/7 RECONDITION /7 DESTRUCTION /7 � <br /> Oq <br /> PUMP INSTALLATION/PtPUMP REPAIR'/� PUMP REPLACEMENT /7 <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 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> ­17'-Domestic/private Drilled Dia. of Well Casing <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 'B : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. n� <br /> PUMP REPLACEMENT: . J / State Work Done <br />'PUMP REPAIR: / J 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 GROUTI G 'AND A PIN INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON' REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY DATE — <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASEXTA1FIN6L INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 9-- 7 <br /> E H 1426 <br />