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{'l JOAQUIN LOCAL HEALTH DISTRIC <br /> F0r,, Oi+FTCE USE: 160r`E. Hazelton Ave . , Stockton, Calif. <br /> f <br /> .. - Telephone : (209) 466-6781 -�� �7 F <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE- ISSUED Date Issued, <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Focal 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. t <br /> JOE ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name 3f1M � �l Phone <br /> Address ��j _ /+tr�liN �>R�-C"/ City 17o- e-k7.�V•y <br /> Contractor's Namezz _ License g�� -P-hone-7-Y1--L-3--k25 , <br /> TYPE OF WORK (Check) : _ NEW�WELL /00f DEEPEN RECONDITION RECONDITION /_/ DESTRUCTION /-7 <br /> f PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> 'Other <br /> DISTANCE �TO NEAREST: SEPTIC TANK /_fo SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT A4VI OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL — <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS i <br /> Industrial''. .. 4, 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 f , Other Information <br /> Geophysical. -,, Surface Seal Installed By <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ,, # H.P. pQ <br /> I � s <br /> PUMP REPLACEMENT: I / / State WorkDone <br /> PUMP .REPAIR: / / State Work Done <br /> i <br />( DESTRUCTION 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 f <br /> and the State of California pertairiing to or regulating well "construction. Within FIFTEEN DAYS ' <br />{ after completion of my work on a new tael•1, T will furnish the San Joaquin Local Health District a <br /> t WELL DRILLERS REPORT of the well and notify them before putting thewell 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 A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) _ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY T DATE _q- 77 <br /> ADDITIONAL COMMENTS: <br /> P HA.S Ez j T OROUtf INSPECTIOXPHASEXJA/FXNAL INSPECTION <br /> INSPECTION BY DATE G INSPECTION BY DATE 7� <br />�:, �- 077 _ 2M <br /> -:�.E',H 1426 Rev. . ]-74 <br />