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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 11 FOE OFFICE iISE; I"- 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, 77" <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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. 1$62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> r 1 <br /> JOB ADDRESS/LOCATION ! <br /> CENSUS TRACT <br /> Owner's Name , tJ I <br /> Phone <br /> Address E <br /> jr <br /> City' <br /> Contractor's Name <br /> C% License #��lJPhone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/—/ RECONDITION / / DESTRUCTION /7 iE <br /> PUMP INSTALLATION / PUMP REPAIR <br /> / / PUMP REPLACEMENT / <br /> Other / J 7-- <br /> DISTANCE <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 WELL ^' { <br /> Industrial CONSTRUCTION SPECIFICATIONS � . <br /> Cable Tool Dia, of Well Excavation <br /> Domestic/private , Drilled Dia, of Well Casing <br /> Domestit/public Driven Gauge of Casing r <br /> Irrigation Gravel Pack _ Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information S E <br /> Geophysical Surface Seal Installed By: 7 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. s <br /> _ I <br /> PUMP REPLACEMENT: State Work Done �' J <br /> 3� <br /> PUMP -REPAIR: <br /> / / State Work Done <br /> i <br />)ES-TRUCTION OF WELL: Well Diameter <br /> - Approximate Depth <br /> Describe Material and Procedure <br /> C hereby agree to comply with all Jaws and regulations of the San Joaquin Local Health District <br /> Ind 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 /> BELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> Lnformation is true to the best ofmy knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TO G TING AND FINAL INSPECTION. <br />;IGNED , TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) ""- <br />'RASE I FOR DEPARTMENT USE ONLY <br />,PPLICATION ACCEPTED BY i DATE <br />,DDITIONAL COMMENTS: <br /> PHASE Ii GROUT INSPECTION PIALIII FINAL INSPECTIQN <br /> NSPECTION BY DATE INSPECTION BY Y, )&Z.,Zk DATE <br /> IT <br /> E H 1426 Rev. 1-74 . 1 /77 qm' <br />