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74� SAN <br /> JOAQUIN LOCAI;-HEALTH DISTRICT <br /> FOSe'OFFICE USE: 1601 E. Hazelton.Ave:, -Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES ,j YEAR•FROM DATE ISSUED Date Issued <br /> (Complete .In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or instar 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 9 3.3 .4 CENSUS TRACT <br /> Owner's Name e Ph <br /> r <br /> p L one 0 0 G <br /> Address - , x . �z _ <br /> � � City <br /> Contractor's Nam : i ,i h' <br /> License oen one d <br /> g p??a7 <br /> TYPE OF WORK (Check}r� NEW WELL /7 DEEPEN Y/7 RECONDITION F7 DESTRUCTION r7 <br /> PUMP INSTALLATION / f PUMP/ REPAIR /. / PUDE' REPLACEMENT <br /> ., Other / .- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY V� . <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 <br /> Industrial Cable Tool Dia. of Well. Excavation <br /> Domestic/private Drilled -Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pacts Depth of Grout Seal <br /> Cathodic Protection — Rotary Type ;of Grout <br /> Disposal Other Other Information <br /> Geophysical. Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ` <br /> eyzdu� ,g am S el �t .�s e laces 76' X_ <br /> PUMP REPLACEMENT: / State Work Done <br /> PUMP REPAIR-:-- —/-7 State-Work Done <br /> ,PES.TRUCTION 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 construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a i <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 FQR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FIN INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> ;FOR DEP. RTMENT USE ONLY <br /> PHASE I - - - <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - 7 <br /> t E H 1426 Rev. 1-74 1_74 W { <br />