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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE, USE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Q Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> Address '(/� f <br /> 4 City <br /> Contractor's Name <br /> License Phone � V <br /> i <br /> TYPE OF WORK (Check) . NEW WELL/-7 DEEPEN RECONDITION RECONDITION /—T DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT /-7 <br /> Other / / <br /> �• T <br /> 1 <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 Drilled Dia, of Well Casing \� <br /> Domestic/public Driven Gauge of Casing k� <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: <br /> Type of Pump H.P.- <br /> 'PUMP REPLACEMENT: / / State Work Done <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 CAT FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND FINAL INSPECTION. <br /> SIGNED TITLE ` <br /> D W Pi, T PLAN ON REVERSE SID-E) 17 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY !/V / DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL SPECTION <br /> INSPECTION BY ATE INSPECTION BY G✓ ATE , / , 6 <br /> E H 1426 Rev. 1-74 376 2M <br />