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}'2 <br /> - s� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOA OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> i Telephone: (209) 466-6781 <br /> .. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. V✓ <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued -3/-7 <br /> (Complete In Triplicate) <br /> ApplicatiOn is hereby made to the San Joaquin Local. Health Districtlaquin <br /> " }�Y <br /> and/or. install the work herein described. a pet-mit to caastruct <br /> an Joaquin <br /> County Ordinance No. 1.862 and the Rules and Regulations tofnnh�S-nis epLo aleHealthwith SDistrict. <br /> I JOB ADDRESS <br /> /LOCATION � <br /> ( CENSUS TRACT <br /> I Owner's Name <br /> Phone <br /> r Address f <br /> r - City = <br /> Contractor's Name 1 <br /> License Phone <br /> TYPE OF WORK (Check): NEW WELL /fi DEEPEN. /-7-_RECOONDITION /? DESTRUCTION r7- -" -- <br /> 'PUMP INSTALLATION % / PUMP REPAIR /� PUMP REPLACEMENT 7 <br /> `Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES } PIT PRIVY � <br /> SEWAGE DISPOSAL FIELD CESS /SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL Y2! PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION.•SPECZFICATZONS � <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public - - DrivenCasing <br /> A <br /> Irrigation Gauge of <br /> Gravel Pack Depth of Grout Seal , <br /> Cathodic Protection Rotary Type of Grout'.Disposal, , Other Other Information <br /> ,_Geophysical "----- <br /> . _ Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> A.P. <br /> PUMP REPLACEMENT: / / State Work Done <br />,. PUMP.-'_REPAIR: r— - <br /> State -Work-Done T <br /> ES;TRUCTION OF WELL: Well Diameter . . „ . <br /> .� �"";"A.``,..'� 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 wi3l.'furnish the San; Joaquin Local Health District a � <br /> WELL DRILLERS REPORT of the well and notify' thele=before putting..the..well in.use.. The above <br /> information is true to the-beat of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIQR TO GROUTING AND A FINAL SpECTION. <br /> TITLE <br /> (D PLO PLAN ON REVERSE Si E - <br /> PHA�� FOR DEPARTMENT USE ONLY - . � <br /> APPLICATION ACCEPTED BY . C <br /> ADDITIONAL COMMENTS: DATE Z <br /> P GROUT INSPECTION " PHASEdtI FINAL INSPECTION <br /> INSPECTION BY DATE ��'� y INSPECTION. BY <br /> /rte DATE <br /> E H 1426 Rev. 1-74 <br /> 1-7 A Im <br />