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AN JOAQUIN LOCAL HEALTH DISTRICT <br /> Ff)BrOFFICE USE:" rherein <br /> l E. Hazelton Ave. , Stockton, Calif. <br /> Telephone (209) 466-6781 <br /> ! ION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. Date Issued <br /> . Y (Complete In Triplicate) <br /> f Application is herebthe San Joaquin Local Health District fir a permit to construct <br /> and/or install the w described. This application is made in compliance with San Joaquin <br /> County Ordinance No. the Ru and Regulations of the Sa J quire L-cal Health District. <br /> JOB ADDRESS/LOCATION I CENSUS TRACT <br /> 4 " <br /> Owner's Name �✓� /�/ I Phone <br /> Address a City ' <br /> o� <br /> r Contractor's Name License d iO Phone ?_222(� <br /> TYPE OF- WORK (Check): NEW WELL /7 DEEPEN /7 RECONDITION /_T DESTRUCTION /7 <br /> PUMP INSTALLATION ] PUMP REPAIR /� PUMP REPLACEMENT <br /> Other /='/ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY, <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY UNE•---PRIVATE DOMESTIC WELL' - PUBLIC DOMESTIC WELL ,1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private b Drilled Dia. of Well Casing G <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation . Gravel Pack Depth of Grout Seal I1 <br /> Cathodic Protection - Rotary Type of Grout <br /> Disposal Other Other Information :, <br /> k Geophysical Surface Seal Inst e By: <br /> PUMP INSTALLATION: Contractor/_/�/ 71Y41 <br /> Type of Pump H.P. <br /> w • <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP '.REPAIR: /7 State. Work Done <br /> PES'TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materialand 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 <br /> i 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 FORA GROUT INSPECTION <br /> PRIOR TO G TING F.1 AI SPE ION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> ® FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA E I INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 . Rev. 1-74 1-74 2M <br />