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M _ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT � *' <br /> F0 OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466 .6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z2 f <br /> _ kl <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ,ISSUED Date Issued7� <br /> (Complete In Triplicate) <br /> Application is hereby"mbde 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. 4862 and the Rules and Regulations of the San -Joaquin Local Health District. <br /> W <br /> JOB ADDRESS/LOCATION /rte I CENSUS TRACT ! <br /> . , . <br /> Owner's Name -� Phone e9,3! <br /> Address C �- City . <br /> Contractor's Name / License # phone ' <br /> �i <br /> TYPE OF WORK (Check): NEW WELL -/DEEPEN /_7 RECONDITION /7 DESTRUCTION % i <br /> PUMP INSTALLATION / / PUMP REPAIR -0-pump REPLACEMENT <br /> 17 <br /> Other /% -- <br /> DISTANCE TO NEAREST: SEPTIC TANK Zae- SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER i <br /> PROPERTY LINE - PRIVATE STIC WELL" PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ' <br /> Industrial Cable Tool Dia. of Well Excavation 01¢ <br /> _ Domestic/private Drilled Dia. of Well Casing _ellf <br /> Domestic/public Driven Gauge of Casing w <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection �( Rotary Type of Groutdn, r <br /> Disposal Other Other Information .16 <br /> Geophysical ---= &4 <br /> Surface Seal Installed "By: <br /> t <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: / 7 State Work Done <br /> PW .REPAIR: r <br /> State Work Done - r <br /> DESTRUCTION OF WELL: ...Well Diameter) Approximate Depth <br /> 'Describe:Material and Procedure 7 - -- <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 ,` ork 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.-wel,l. in.nse_. . .The above <br /> information is true to the-best -of- my knowledge and belief. I WILL CALL FOR A -GROUT INSPECTION <br /> PRIOR TO GROU NG A FINAL E ON. � <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> .E <br /> APPLICATION' ACCEPTED BY # <br /> ADDITIONAL COMMENTS: DATE -77 <br /> PHASE iI GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY ^ DATE INSPECTION 13Y DATE <br /> " ►" <br /> E H 1426 ` .lag..._ .�`"- � f=.�� �'� <br /> . Rev. 1-7�i r, 1J7c ou <br />