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SAN JOAQUIN LOCAL HEALTH DISTRICT !,f <br /> FOS OFFICF, USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 /y� <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 he 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 / 77rs? 9-S Z_ -I,, It r- dRel CENSUS TRACT <br /> Owner's Name �,px . 4 gd be fifes r Phone F97- a"F <br /> Address X'_N._ jrr 7- - �4/Kela City <br /> Contractor's Name 110A ,G Ole, 111A,+ �,�, License �OO PhoneQyl47;;tS' <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN RECONDITION RECONDITION /_/ DESTRUCTION /7 _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / / <br /> 'Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 6-5`' PIT PRIVYr <br /> SEWAGE DISPOSAL FIELD 7,6 CESSPOOL/SEEPAGE PIT _ OTHER <br /> PROPEAtY -LINEi 'RIVATE DOMESTIC WELL A-0-_f PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS . <br /> Industrial Cable Tool Dia. of Well Excavation - 12,41 " <br /> - Domestic/private Drilled Dia, of Well Casing _ fl <br /> Domestic/public ,F Driven Gauge of Casing Afl Avc...---_- - <br /> Irrigation Gravel Pack Depth of Grout Seal K'� - <br /> Cathodic Protection Rotary Type of Grout e0e_A. <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor rfA1)` <br /> Type of Pump H.P. <br /> f <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 agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well 'constructi.on. Within FIFTEEN DAYS <br /> after completion of my work on a new well, 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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUPING AND A FINAL I. PECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE .ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE - <br /> ADDITIONAL COMMENTS: _ <br /> PHAS I GRO INSPECTION P' SEA /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE `z "�27 <br /> � y zTa <br /> ' <br /> E H 1426 r Rev. - I-74� "W 6V't/� ��� � � <br />