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SAN; JOAQUTN -,LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: 1601 E. kazel'ton AveW, Stockton, Calif. , <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit'lNo. zd <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) 11 <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. 1862 and the..-Rules and 'Regulations of .the San Joaquin Local Health District. <br /> ---w 3 �I <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Namep Licens �7 7 Ph.ll`e �S�Z <br /> i�. <br /> I i <br /> TYPE OF WORK (Check) : NEW WELL L-_7 DEEPEN;]?" RECONDITION / / DESTRUCTION /_7 <br /> PMP INSTALLATION / PUMP REPAIR / I PUMP REPLACEMENT /1 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER? j <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WEL`L=. <br /> INTENDED USE TYPE OF WELL CONSTRUCTION. SPECIFICATIONS �1• <br /> Industrial Cable Tool Dia. of Well Excavation 1M <br /> Domestic/private Drilled Dia. of Well Casing"� <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 1 <br /> Cath`odit.. Protection Rotary�Q Type of .Grout <br /> Disposal Other t.�c-Pd� Other Information <br /> Geophysical. — .Surface Seal Installed By: �I <br /> PUMP INSTALLATION. Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: . / / State Work Done'. <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Deg�th * <br /> Describe Material and Procedure I� <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the Stare of California pertaining to or regulating well'construction. Within (FIFTEEN DAY$ .- <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 /> information is true to the best of- my knowledge and belief. I WILL 'CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU NG FIN6& INS ECTION, <br /> SIGNED TITLE <br /> (DRAW PLAN 'ON FRSE SIVE <br /> FO DEP USE ONLY <br /> PHASE I - <br /> APPLICATION:.ACCEPTED BY � v DATE Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P IYIIFXNAL IOW. <br /> INSPECTION BY DATE INSPECTION BY DATEI� d <br /> E H 1426 Rev. 1-74 <br /> 3/76 � <br />