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r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOSjOFFICE USE: V'1601 E. Hazelton Ave. , •Stockton, Calif. <br /> Telephone- ,24(209) 466=6781 <br /> APPLICATION FOR WELL' CONSTRUCTION OR PUMP PERMIT Permit No. 7 - 991lJ <br /> i <br /> THIS PERMIT RXPIRES 1 YEAR.FRO DATE ISSUED Date Iasuec4a �_ <br /> £ w (Complete In .Triplicate) <br /> Application ie heieby„shade to the San Joaquin Local Health Distriet: fosr a permit to construct <br /> and/or install the-work herein described. This .application •is made•in>compliance with San Jciaquin <br /> County OrdinanceWNo •186 d he Rule,s , -Regulattony of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONrSUS TRACT <br /> ' Owner's Name �-�[�t <br /> Phone ,� V/41 l <br /> Address n. .- 'Ci <br /> ty <br /> Contractor's Name 0License <br /> Phone�� Z <br /> TYPE OF WORK (Check): : NEW WELL/77-�EEPEN'-/7 RECONDITION _ x <br /> /� :. DESTRUCTION /'7 <br /> PUMP ,INSTALLATION /44-;�:FUMP REPAIR PUMP REPLACEMENT <br /> Other E7 <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 LL .CONSTRUCTION SPECIFICATIONS <br /> Industrial Viable Tool Dia. 'af Well Excavation <br /> = �- omestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven __?__Gauge of Casing <br /> ! Irrigation ,�, . Gravel Pack Depth of Grout Seal <br /> Cathodic Protection y e Rotary <br /> Type 4 - <br /> of Grout <br /> Disposal Other Other Information <br /> Geophysical -� Surface Seal Installed B 6 /x <br /> PUMP INSTALLATION: Contractor 00, <br /> a <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: Ll State Work .bone <br /> PUMP :REPAIR-. -�. _ -t=-_ /77 -State`Work-Done <br /> - <br /> PES; ?,UCTION 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 put <br /> ting.. tlie..well in use.. The above <br /> information is true -to the-best of'my:knowledge and belief. I 'MILL" CALL FOR -A -GROUT INSPECTION <br /> PRIOR TO GROUTINQ AND AFI INSPECTION. <br /> SIGNED TITLE <br /> 4 (DRAW PLOT PLAN ON REVERSE SID <br /> ' FOR .DEPARTMENT USE ONLY <br /> PHASE I r <br /> AP / <br /> PLICATION ACCEPTED BY C E� DATE /o/�5—1-7 <br /> ADDITIONAL COMMENTS: / 77g >r <br /> PHASE II G OU INSPEGTIO co ` <br /> PHASE III FINAL INS ECTION/ <br /> INSPECTION BY DATE / � 7 INSPECTION BY DATE <br /> y; VE H'1426 Rev. 1-74 !r` - <br />