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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOAOFFICE USE: 1601 E. .Hazelton .Ave. , Stockton, Calif. <br /> Telephone: . (209) 466=6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �,6-O/W <br /> THIS ,PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,/:/,2- <br /> (Complete <br /> ssuedf:/,2-(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 Joaquin ; <br /> County Ordinance No.;-1862 and the Mules andRegul ions of the San Joaquin Local Health District. i <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner:s Name Phone 931--o yU z_ ,- <br /> Address City <br /> Contractor's Name ::LicenseyPhone 7 a <br /> -TYPE-.OF WORK (Check)_:. -NEW WELL" %�_ELL /-_ .DEEPEN RECONDITION /_=7 DERSTRUCTIOid_/ �j <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP EPLACRMENT _j f <br /> Other <br /> DISTANCE TO NEAREST:- SEPTIC TANK SEWER LINES ' PIT PRIVY <br /> SEWAGE�DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER (�y <br /> { t <br /> PROPERTY-:LINE--- PRIVATE-DOMESTIC-WELI;-."" ,PUBLIC DOMESTIC WELL \ <br /> "INTENDED USE TYPE OF- WELL, CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Ekeavation �- <br /> Dome6tic/private Drilled .r = Dia. of Well Casing,,, „ <br /> Domestic/public i Driven '.- Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal . Other Other Information \ t <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: ' Contractor <br /> Type' of Pump H.P. <br /> PUMP REPLACEMENT / ] State Work Done <br /> � <br /> � /� ;S; <br /> PUMP 'REPAIR; � 'tate Work Done <br /> j2E&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' Californi.a 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-GROUTRINSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED aq TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br />{ APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA I F•I AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE . <br /> 1426 Rev. 1-74 1-74 2M <br />