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SAN .JOAQUINLOCAL HEALTH DISTRICT <br /> n FOR(OFFICE VS 1601 E. Hazelton Ave., Stockton, Calif. 3 <br /> Telephone: (209) 466-5781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ' S�p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In In Triplicate) <br /> I 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 Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �'/ .S CENSUS TRACT <br /> Owner's Nance ¢S L Phare 44G z 3yo f <br /> Address g S'/ ,``' ro i 1 ---- City <br /> Contractor's Name License # Z S Phone 6 <br /> TYPE .OF WORK :(Check)_ .NEW •WELL ,/7 DEEPEN'/7­- RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION /7 7PUMP REPAIR /� PUMP REPLACEMENT 5-7 T <br /> 77 <br /> Other /7 — a�! 1 u 1 t t•j 0/_/ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES__ PIT PRIVY <br /> SEWAGEDISPOSALFIELD CESSPOOL/SEEPAGE PIT OTHER <br /> = PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS MIndustrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/;public Driven Gauge of Casing <br /> Irrigation Gravel Pack"' Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical 'Surface Seal Installed By: <br /> -:PUMP INSTALLATION: Contractor <br /> Type •of H.P. <br /> / y <br /> PUMP REPLACEMENT: /)C/ State Work Done d �� �. -, cf-- z-f � <br /> 1. ' PUMP REPAIR: /7 State Work Done - _ <br /> -- - — <br /> 2ES TRUCTION OF WELL: Well Diameter - k Approximate Depth <br /> ^- Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the SanJoaquinLocal Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of mywork on a new wel1, .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 knowledWand' eli WILL CALL FORA GRO INSPECTION <br /> PRIOR TOG 0 ING AND FINAL CTI-ON <br /> SIGNED (DKAW PLON ERSE SIDE <br /> FOR POARTMMT USE ONLY <br /> `. PHASE I / <br /> APPLICATION ACCEPTEDBY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III F NAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY All DATE <br /> E H 1426 Rev,. 1-74 1-74 2fi <br />