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+ GQ Q SAN JOAQUIN LOCAL-HEALTH DISTRICT <br /> " FORrOFFICE USE: 1601 E. Hazelton Ave.,, S.tockt'on,' Calif. <br /> Telephone: . '(209) 466"=6781 <br /> APPLICATION FOR WELL CONSTRi CTION OR PUMP PERMIT Permit No. 7.41,5'7,)v <br /> THIS PERMIT EXPIRES l.' YEAR FROM DATE>ISSUED Date Issued L-14,1-7h <br /> (Complete. In Triplicate) - <br /> Application is hereby made •to the San Joaquin. Local Health District :for a permit to construct <br /> and/or install .tt}e.work herein described:.,•.This application, is made.,in compliance with San Joaquii <br /> County Ordinance. No. 18.62 and the Rules .and .Regulations.of;.the-San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Lv .- CENSUS TRACT <br /> Owner?s Name Phone <br /> Address. tiil�� City SSC,9Lu <br /> Contractor's Name 1. ��� �,� License. #c21-'9d/t3 Phone <br /> F r <br /> TYPE OF WORK (Check): NEW WELL /77 DEEPEN j-7 RECONDITION /_ DESTRUCTION f7 <br /> ,PUMP21NSTALLATION � PUMP REPAIR L-7 PUMP REPLACEMENT f7 <br /> Othiar.../ 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/.SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE . TYPE OF WELL %.., CONSTRUCTION SPECIFICATIONS 1 <br /> Industrial' Cable Tool Dia. of Well Excavation <br /> Domestic/private ', Drilled- Dia. of Well Casing <br /> Domestic/public ' Driven I `. Gaugel' of Casing IN <br /> Irrigation Gravel' Pack 'Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Informatio <br /> x GeophysicalSurface Seal Insta led By- <br /> N­ <br /> yN 4 �Ij ... <br /> PUMP 'INSTALLATION: S" <br /> Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ;•ti`�•/ /` S tate Work Done <br /> per,:a REPAIR: / 'State 'Work Done""°""''"' - - _• _ R r _. <br /> ES-TRUCTION OF WELL: Well Diameter k <br /> 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 construction. 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 FO 'A GROUT INSPECTION <br /> PRIOR TO GROUTI A FIN INS ECTION.- <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B DATE - 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE "" INSPECTION BY DATE -a •' <br /> � � <br /> E '11 1,426 Rev. 1-74 1-74 2M <br />