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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EOR.OFFICE USE. 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> RxICATIO' N FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPTRES 1 YEAR FROM DATE ISSUED <br /> Date Issued <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 <br /> io! 11 <br /> CENSUS TRACT <br /> Owner's Name114- 1111111'oI I Z__ <br /> j <br /> Phone -� <br /> Address <br /> City <br /> Contractor's Name <br /> 1 - <br /> .License # hone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPENQ a <br /> RECONDITION /_/ ENT DESTRUCTION /� <br /> / <br /> PUMP INSTALLATION PUME' REPAIR / PUMP REPLACEM /_7Other / / — , <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL Industrial TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of WellDomestCasing <br /> Irrigation <br /> Driven IGauge of Casing <br /> Irxigation -� Gravel Pack 'Depth of Grout Seal pJ I <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other <br />� Geophysical ' � Other Information <br /> Surface Seal Installed B : , <br />'UMP INSTALLATION: "J <br /> Contractor L <br /> Type of Pump <br /> H.P. <br />'UMP REPLACEMENT: / / State Work Done <br />'UMP -.REPAIR: / / State Work Done ° <br /> ES•TRUCTION OF WELL: Well Diameter q <br /> Describe Material, And. Procedure Approximate Depth ` <br /> hereby agree to comply with all laws and regulations of the San Joaquin LocalHealth istrict <br /> ad the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> fter completion of my work on a new well, I will furnish the San Joaquin Local Health District 8 <br /> ELL DRILLERS REPORT of the well and notify them before putting. the..well in use. The above <br /> aformation is true to the best of my knowledge and belief. I WILL L FOR A GROUT. INSPECTION <br /> ZIOR TO R UTING AND FINAL NSPECTION. <br />[GNED ,:' <br /> TITL ` <br /> (DRAW PLOT PLAN ON REVERSE SIDE I <br /> iASE T <br /> FOR DEPARTMENT USE ,ONLY <br />?PLICATION ACCEPTED BY <br />)DITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION P SE I /FIN INSPECTION <br /> JSPECTION $Y INSPECTION BY <br /> l DATE 77- / 7_7 7 <br /> E H 1426 Rev. 1-74 <br />