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. FOR OFFICE USE: .. r�=� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 2601 E. Hazelton Ave' ,. <br /> ' Stockton, Calif. <br /> ,,,-�Tel.ephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT / ! ' M It <br /> Permit No. <br /> THIS"PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ` <br /> Date Issued -Z 9-77 <br /> Application is Aereby made to` the San (Joaquin eLocal rHealth District.for <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> a permit to construct k <br />�,Cqunty Ordinance No. 1862 and the Rules and Regulat'o o£ the San Joaquin Local <br /> r t2�Y:q"3 �'"! " u't� Health District. <br /> JOB ADDRESS/LOCATION j <br /> CENSUS TRACT' D l7- 2lPp.�7 <br /> Owner's Name a ' <br /> Phone <br /> Addressf.3 f <br /> City <br /> Contractor's Name . <br /> LicensJ c._ Phone� S <br /> TYPE OF.WORK (Check) : NEW WELL '/ DEEPEN <br /> �/ RECONDITION /_/ DESTRUCTION- /_7 <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC TANK �- <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT i <br /> USE <br /> PROPERTY. LINE - PRIVATE DOMESTIC WELL PUBLIC DOMES OTHER <br /> INTENDED TYPE OF WELL TIC WELL <br /> IndustrialCONSTRUCTION SPECIFICATIONS r <br /> I Cable Tool Dia. of Well Excavation <br />" 6mestic/private Drilled <br /> -Dome�sta.c/public- -- t rt ._ Dia. of Well Casing W, <br /> w Irrigation Driven�" Gauges of�Casin• <br /> Gravel Pack g�°�a��'�-'ter-..o"�"-. <br /> Cathodic P`rotection� Depth of Grout Seal ; <br /> -lC,Rotary Type of Grout <br /> Disposal Other <br /> Geophysical Other Information <br /> ��.,,� Surface Seal Installed B : <br /> PUMP INSTALLATION: <br /> Contractor <br /> Type of Pump <br /> H.P. . . . _ F <br />'UMP REPLACEMENT / / State Work Done <br />'UMP--REPAIR-: ...._ �:. .�,. �..a ` <br /> Staate-Tork Done- <br /> ES•TRUCTION OF WELL: Well Diameter <br /> - <br /> Describe Material and Procedure Approximate Depth ' <br /> hereby agree to comply with all laws and regulations of the-'San Joaquin Local health bistric ' <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 wall furnish the San Joaquin Local Health District a <br /> ELL DRILLERS REPORT of the well and notify them before putting the .well in use. The above. <br /> nformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> ZIOR TO GROUTING AND A FINAL I PECTION. <br /> IGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) s <br /> iASE I FOR DEPARTMENT USE ONLY <br />?PLICATION ACCEPTED BY r <br />)DITIONAL COMMENTS: DATE. 7 a 2-�.7 1 <br /> PHASE II GROUT INSPECTION. . <br /> JSPECTION BY PHASE I I/FINAL INSPECTION <br /> DATE _ �f. l _ INSPECTION BY DATE <br />'`E H 1426 Rev. -I-74- <br /> ---- __ <br />