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SAN JOAQUIN LOCAL"HEALTH DISTRICT <br /> FOR OFFICE USE: 1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL 'CONSTRUCTION OR PUMP PERMIT Permit No. 7 1 r <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedSy.'7 <br /> (Complete In Triplicate) �T'"�`�� <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 JoeQuinl <br /> County Ordinance No. 1862 and the Rules and Regulations of 'the San Joaquin Local Health District. <br /> JOB ADDRESS/L nrlQ' '0 f �7 <br /> CENSUS TRACT <br /> Owner's Name � <br /> Phone <br /> Address <br /> City <br /> Contractor's Name <br /> License # j &Ohone Q <br /> TYPE OF WORK- (Check) ; NEW WELLti <br /> DEEPEN `/ �"/. RECONDITION / / DESTRUCTION /_7 <br /> PUMP INS ALLATION PUMP REPAIR / / PUMP REPLACEMENT- 1-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK Y EWER=LINES PIT PRIVY <br /> SEWAGE DISP IELD/&0-f- <br /> SSPOOL�SEEPAGE PIT .�-.•� OTHER <br /> PROPERTY LIN RIVATE DOMESTIC WELIi7&_ PUBLIC DOMESTIC WELL <br /> TNTENDED USE TYPE OF WELL � CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool`, Dia. 'of Well Excavation <br /> Domestic u <br /> /private � Drilled Dia. of Well Casing ' <br /> Domestic/public Driven _ Gauge of Casing <br /> Irrigation GravelPackDepth of Grout Seal <br /> Cathodic Protection. �/ Rotary Type of .Grout _ ---� <br /> Disposal —7�- Other Other Information— <br /> Surface <br /> nformation <br /> Geophysical Surf ace Seal Installed B <br />'UMP INSTALLATION: <br /> Contractor <br /> Type of Pump H.P. <br /> - i <br />'UMP REPLACEMENT: / / State Work Done <br />'UMP .REPAIR: State Work Done <br /> ES•TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> r <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local. Health District <br /> nd the State of California pertaining to or regulating well ''construction. Within FIFTEEN DAYS <br /> fter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> ELL DRILL•ERS 'REPORT of­-the"welI- y-tlm_bfore <br /> And'notif� i6e � -� <br /> nformation is true to the nest of m know _b6fore ­ the .weT1 in use.. The above <br /> RIOR TO GROUTING AND A FINAL INSPECTION ge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> IGNED <br /> E I <br /> 1 ( PL PL N REVERSE SIDE) ! <br /> RASE I <br /> FOR--DEP TMENT USE ONLY <br /> - _. _• � E <br /> PPLICATION ACCEPTED BY ,. DATEq (� - <br />)DITIONAL COMMENTS: <br /> PH4SE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> VSPECTION BY DATE p INSPECTION BY DATE <br /> L . <br /> M <br /> g�,H 1426 Rev. 1-74 . 1 .477 OM 1�. <br />