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SAN 'JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209)., 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> f <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <br /> F.� . (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 Joaquii <br /> t.: County Ordinance No, 1862 and the Rules and Regulations of the San Joaquin Local Heal.th. District. <br /> JOB ADDRESS/LOCATION �� /{'� CENSUS TRACT ' <br /> Owner's Name r� , Phone 9-moi 1 <br /> r Address. s <br /> C i t ;* - 72,- <br /> Contractor's Name License <br /> 1126 <br /> gZ,rl Phone r <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION DESTRUCTION <br /> 4 PUMP INSTALLATION /cam PUMP REPAIR / / PUMP REPLACEMENT /-J <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK -&.dZ0-.,4SEWER LINES / <br /> Or--'-fk 1PIT PRIVY <br /> SEWAGE DISPOSAL'•FI-ELD— P -CESSPOOL%SEEPAGE-PIT OTHER 90C- <br /> PROPERTY LINE1,42 PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> t <br /> Industrial Cable Tool Dia. of Well Excavation <br /> i __,q_-. Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal S <br /> Cathodic Protection - Rotary, Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> k <br /> PUMP INSTALLATION: Contractor �f <br /> Type of Pump <br /> t -t H.P. <br /> PUMP REPLACEMENT: <br /> / / State Work Done <br /> PUMP .REPAIR: ' <br /> State Work Done <br /> DESTRUCTION OF WELL: Well Diameter. <br /> + <br /> Describe Material and Procedure Approximate Depth <br /> I" 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 <br /> PRIOR TO GROUTING.; D, �FINA�LI�S�PECT�DIN <br /> . <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) i <br /> �... .,• �, _ F R-D ARTMEN-T--USE-ONLY - <br />` PHASE I � _ <br /> APPLICATION ACCEPTED BY r- ,. ; , , 1 DATE <br /> ADDITIONAL., COMMENTS: �. _ _t ._. _ - <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> ,INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. .1--7.4 _. // x/77 2M <br />