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SAN JOAQUIN LOCAL HEALTH- DISTRICT ` <br /> FOE OFFICE 'USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> AVPPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 9): r <br /> " THIS PERMIT EXPIRES 1 YEAR. FROM DATE ISSUED Date Issued T� <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 r Phone <br /> Address Pal City <br /> Contractor's Name urr--. License #/y ,3 Phone �$ <br /> - r: r <br /> TYPE OF WORK (Check) :, NEW WELL / IT DEEPEN /7 RECONDITION /-7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR'L / PUMP REPLACEMENT f7 <br /> Other <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGEiDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL q <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS fv <br /> .Industrial ! Cable Tool Dia, of Well- Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation I Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 1 Rotary Type of Grout <br /> Disposal "` f 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 <br /> "PUW7REPAIR:. =" —State Work-Done _ <br /> �- v V_ - - <br /> DES•TRUCTION,'OF_WELL: Well Diameter , v Approximate a D9pth <br /> Describe Material and Procedure <br /> I .hereby agree to comply with all laws and regulations of the San Joaquin Local Health Distri.c•t <br /> and the State of California pertaining to or regulating well construction. Within FIST M DOS <br /> after completion of my work 6n 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 isLtrue to the.'best of my.knowledge and belief. - I'WILL CALL FORA GROUT I.NSPECTI0i <br /> PRIOR 'TO ROUTING AND A FINAL INSPECTION. <br /> SIGNED F / TITLE <br /> D PLAN ONRSE SIDE <br /> . ; FOR D PARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPT L DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE If GROAT INSPECTION PRAS"IZFINAL INSPECTION <br /> INSPECTION BY - DATE , '= INSPECTION B DATE Z _7 <br /> V76 2$-- <br /> E H 1426 Rev. 1-74 <br />