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JOAQUIN LOCAL HEALTH DISTRICT <br /> r <br /> ;OFFICE USE: 1601 E. Hazelton Ave. , Stockton;-Calif. <br /> Telephone: ..(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76- 7s <br /> .74-. vp <br /> THIS PERMIT EXPIRES I FEAR FROM DATE -ISSUED Date Issued. <br /> (Complete In- Triplicate) <br /> Application is liereby' made to the San Joaquin Local ,flealth District for a permit to construct <br /> and/or install the work herein described. This application is made incompliance with San Joaquini <br /> County Ordinance Na 1862 and the Rules and Regulations',of the .San Joaquin Local Health District. <br /> JOB ADDRESS/t9C0'1 CENSUS TRACT <br /> Owner's Name (� J Phone j <br /> Address City I <br /> ' 1 I <br /> Contractor s NameS License Phone <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN/7 ,RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INST LATION P3UMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE- TO NEAREST: SEPTIC TANK ®y SEWER LINES Z&O PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEE AGE PIT/ _ OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL-= PUBLIC DOMESTIC WELL` <br /> INTENDED USE ,, w TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial_, Cable Tool Dia., of Well Excavation <br /> L.-Domestic/private L.-Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing ,Gc <br /> Irrigation Gravel Pack Depth of Grout Seal _�S� <br /> Cathodic Protection, 4 Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical ,.. Surface Seal Installed .B <br /> PUMP INSTALLATION: Contractor ®Q Yt leo? <br /> f Type. -of Pump � 0 H.P. <br /> PUMP REPLACEMENT:,,,L_1 State Work Done <br /> PUMP .REPAIR: ' / / State Work Done <br /> DESTRUCTION 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 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` k <br /> PRIOR TO GROUTING AND A FINAL INSPECTIO <br /> SIGNED �TLEy <br /> (MUW PLOT ON REVERSE SIDE ._ <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY DATE —„� <br /> ADDITIONAL COMMENTS <br /> PRASE II GROUT INSPECTION PHASE III INAL INSPECTION <br /> INSPECTION BY DATE 16 L/:7 b INSPECTION BY 0. DATE <br /> Eli 1426 Rev. 1-74 h/75 2M <br />