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SAN 30AQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE: US•E �,._�1sFO1 E. Hazelton Ave. , Stockton, Calif. f i� <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 l' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (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 Rules and Regulations of the San Jo aquin Local Health District. <br /> • CENSUS TRACT � <br /> 30B ADDRESS/LOCATION �� <br /> Phone `�� <br /> Owner's Name <br /> City <br /> Address <br /> License ib& Phone <br /> Contractor's Name i <br /> Z,3 <br /> TYPE OF WORK (Check) : NEW RWELL / - $ EPEN / IRECONDITIONk,/ /+� FDESTRUCTION <br /> PUMP INSTALLATION/% ' 'PUMP REPAIR/ /`� PUMP REPLACEMENT <br /> Other <br /> DISTANCE T,0 NEAREST: SEPTIC TANK SEWER LINES PTT PRIVY 1 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SCATION <br /> PECIFI <br /> Tool Dia. of`;Well Excavation ' <br /> Cable Too <br /> Industrial �. , <br /> Domestic/private Drill-ad Dia. of Well Casing _ <br /> 'rstic/publiC'TDriven " -. Gauge of Casing 2 <br /> Gr vel Pack Depth of Grout Seal <br /> Irrigation ✓, <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal ,Other Other Information fi <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: ` 'Contractor �; <br /> H.P <br /> Type of Pump , . T <br /> PUMP REPLACEMENT: /�/ 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 agxP Y <br /> ee to com 1 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 .I3AY5 <br /> after completion of my work on a new well, I will furnish Joaquin Loca lth District a <br /> WELL DRILLERS REPO of the well;an notify wham befor putting the 11 in us a NabovC ON <br /> information is to the bes o y�knowledge and belief. I WILL LL FORS <br /> PRIOR TO GROU .AND A FINAL I ION. �'Jr <br /> f ✓ TITL <br /> SIGNED <br /> DRAW PL T`P-LAAll <br /> N ON RE RS <br /> FOR DEPARTMENT`US LY . <br /> PHASE I DATE (/— <br /> APPLICATION ACCEPTED BYE`$ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT IN CTION P E II/ INAL INSPECTION <br /> INSPECTION BY <br /> DATE INSPECTION BY DATE , _7 <br /> 3/76 2M <br /> s E H 1426 Rev. 1-74 <br />