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SAN JOAQUIN LOCAL. -I;'i.EALTH DISTRICT <br /> FOR;OFFICE USE: 1601 E. Hao; ton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77_ 7- <br /> THIS PERMIT EXPIRES l YEAR FROM DATE 'ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made Co the San Joaquin Local Health District for a permit to construct F <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 Re ulati�ons of th San Joaquin Local Health District. <br /> i! <br /> JOB ADDRESS/LOCATION (� �� <br /> CENSUS TRACT <br /> Owner's Name ___4Phone ' �- <br /> Address f <br /> City <br /> Contractor's Name License R#, Phone: o i <br /> TYPE OF WORK '(Check) : NEW WELL , DEEPEN/? RECONDITION /7 DESTRUCTION 17 <br /> PUMP INSTFLATION / / PUMP REPAIRPUMP P <br /> /� RE LACEMENT /? , <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC"TANK SEWER LINES PIT PRIVY <br /> SEWAGE-DISPOSAL FIELD CRSSPOOL/SEEPAGE PIT OTHER Q , <br /> PROPERTY`LINE PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL � <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICAT ONS <br /> Industrial Cable Tool Dia. of Well Excavation <br />---6 Domestic/private � . Drilled I Dia. of Well Casing p <br /> Domestic/public Driven Gauge of Casing <br /> .. Irrigation' Gravel Pack .Depth of Grout Seal <br /> Cathodic Protection Rotary Type of <br /> Disposal Other Other Information ' ' ' :Geophysical Surface Seal Instal ed 'B 3 <br /> PUMP INSTALLATION: Contractor ~ <br /> - Type .of Pump ,, H.P. . <br /> PUMP REPLACEMENT: ' / / State Work Done �0 <br /> PUMP .REPAIR: ' <br /> ., / / State Work. Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> ;:Approximate Depth <br /> Describe Material and Procedure <br /> 3 <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 anew well, I will furnish the San Joaquin Local Health District <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 GRO ING 'AND A FINAL INSPECTI . <br /> SIGNED } TITLE AA <br /> .w <br /> DRAW PLOT ON REVERSE SID <br /> FOR D ARTMENT USE ONLY <br /> PHASE I J <br /> APP IL CATION ACCEPTED BY DATE � f <br /> ADDITIONAL COMMENTS: <br /> 110, <br /> PHASE II GR INSPECTION P E13ENAL INSPECTION <br /> INSPECTION BY ATEr 7 INSPECTION BY DATE <br /> i <br /> E H 1426 Rev. 1-74 � _ i <br /> _ I i 17� 9T+I 1 <br />