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i <br />! SAN JOAQUIN LOCAL Ht.QLTH DISTRICT <br /> FOF, FFICE USE: 1601 E. Hazelton Ave. ,-Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> f <br /> THIS PERMIT EXPIRES 1 YEAR 'PROM DATE 'ISSUED Date Issued <br /> ! i <br /> f „ (Complete In Triplicate) <br /> Application is hereby made to"the .Sari 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 />[ Couny Ordinance No: 1862 and' the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB `ADDRESS/LOCATION p� 7 VA)*f n �kjl CENSUS TRACT <br /> .-Owner's Name �^Phone " ���. 0� . <br />�. Address t �- <br /> City <br /> Contractor's Name F -Licens.e #&LE213P.hone <br /> i <br /> j TYPE OF WORK (Check): NEW WELL / / DEEPEN'P �`�RECONDITION /_7 DESTRUCTION /_7 <br /> 4' PUMP INSTALLAT ON / J PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other i/ 14% <br /> DISTANCE TO'NEAREST:�SEPTICTANK _E4274-- SEWER LINESv'�d f' PIT PRIVY r w <br /> SEWAGE DISPOSAL FIELD'`".�i CESSPOOL/SEEPAGE PIT �..r OTHER <br />�,_.'• <br /> PROPERTY ,LINE PRIVATE _DOMESTIC WELL ,�7f"FUBLIC DOMESTIC WELL <br /> INTENDED USE aTYPE OF WELL f ' CONSTRUCTION SPECIFICATIONS J <br /> Industrial ` Cable Tool - � Dia, of Well Excavation <br /> ( Domestic/private ; " ' 'Dr'illed .^ , Dia, of Well Casing 1-!* <br /> Domestic/public Driven Gauge of Casing �' t , <br /> Irri ation <br /> g . ? Gravel Pack 1 Depth of Grout Seal <br /> Cathodic Protection I_!_ .Rotary ,: Type of Grout m <br /> 1 ' <br /> Dis osal <br /> P ."�"� y�� Other— Other Information <br />' Geo hy si ° <br /> p cal '" _ S rface_S_eal Installed B <br /> PUMP INSTALLATION: <br /> Contractor �_ <br /> Type of¢Pump,^....,[ w 4. "mo b H.P. <br /> PUMP REPLACEMENT: State Work Done i <br /> PUMP '.REPAIR <br /> _ State Work`Done 12 <br /> .- <br /> AF <br /> 'DES-TRUCTION OF WELL: Well Diameter Approximate Depth, <br /> A 7 DescribeL.Mater.ial„and Procedure <br /> I hereby agree- to comply with all-laws and-'regulaEions of the San Joaquin Local Health District <br /> :and the State of California pertaining to or regulating well ''construction, Within FIFTEEN DAIS <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 /> j,,informati:on -is true to the best gf my knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> ,,PRIOR .TO GROUTh. I D A F PECT10 � <br /> `SIGNED <br /> TITLE <br /> ! (DRAW PLOT PLAN ON REVERSE_SIDE) ._ <br /> i <br /> FOR DEPARTMENT -USE ONLY A� <br /> PHASE I <br /> APPLICATION ACCEPTED BY �- DATE �� 7e ice' <br /> ADDITIONAL COMMENTS: , <br /> PHASE II GROUT INSPECTION <br /> P 5E III/FINAL INSPECT N <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev.. 1-74' 1 177 _. 2M ":4, <br />