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t <br /> G SAN JOAQUIN LOCAL HEALTH DISTRICT - - <br /> 0 fWFICE USE: 1601 E. Hazelton Ave. , Stockton- Calif. 77-74 <br /> Telephoner (209) 466-678T 77'42, 0' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a pe=it to construct <br /> and/or install the work herein described, - This application -is made in compliance with San Joaquin <br /> County Ordinance No. x.862 and the Rules and- Regulations of :the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION. CENSUS TRACT <br /> Owner Is Name &45 (j-, Phone •C <br /> -6 <br /> Address <br /> i •'` �� :•�, City <br /> -Contractor!s .Name . l ` • ' 1 <br /> -License-� ��-Phone Q --. <br /> TYPE OF WORK (Check) NEW WELL DEEPEN / / RECONDITION /? DESTRUCTION /_7 <br /> PUMP INSTALLATION / PUMP REPAIR 1_7-PUMP REPLACEMENT 17 <br /> iOther / 7 <br /> DISTANCE TO NEAREST: SEPTIC TANKp SEWER LINES LJro ` PIT PRIVY <br /> SEWAGE DISPOSIE�FIELD CES POOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELLPUB LIC DOMESTIC WELL O <br /> ` INTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial _I::-_ Cable Tool Dia. of Well Excavation <br /> �Domestic/private Drilled Dia. of Well Caning .- <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout _jamsp7f' <br /> Disposal ' Other - Other Information <br /> Geophysical Surface Seal Installed ,Bv: Lt/oo S <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump .., <br /> B.P. <br /> PUMP REPLACEMENT: j//_ State Work Done �� { <br /> PUMP !REPAIR: � /_7 ...,.,.�:.�..��._.,.•. �... �.T „�,.,.,.._ _�-�.�------_.,�.-�..- � _..,,�.- ,--- _T.�,-.V,.�:R,r-�-�t <br /> State Work Done <br /> j <br /> ES;TRUCTION 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`Healih District a <br /> WELL DRILLERS REPORT of the well and notifythem before <br /> 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 GROUTING AND A FINAL INSPECTION. <br /> SIGNEDliaTITLE <br /> ~ (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT'USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED BY DATE -e," 2- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE IIJNSPECTiON.BY 4.— <br /> DATE <br /> E H 1426 Rev. 1-74 �i <br />� -_ 1-7 4 2M <br />