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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> --f—or,-"OFFICE USE: & "1601 E. Hazelton Ave. , 'Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMITPermit No. -77- -)3'7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /ice 7 7 ' <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 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 /> r,J; <br /> JO 070- 0� � <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION 4AA,,g,, &2�2 <br /> Owner's Name Phone <br /> Address City �yJ <br /> Contractor's Name License # �� Phone �b � <br /> i <br /> TYPE OF WORK (Check) : NEW WELL /7/ DEEPEN RECONDITION RECONDITION / DESTRUCTION <br /> AL /? <br /> PUMP INSTLATION �I I PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other / <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 O 1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ~ <br /> Industrial Cable Tool Dia. of Well Excavation fri <br /> Domestic/private Drilled- Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing Z <br /> Irrigation Gravel Pack 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: <br /> Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /V7 State Work Done <br /> PUMP..REPAIR:- -— T / / State Work Done - <br /> i <br /> DES-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 <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 ROUTING AND A FINAL INSPECTION. <br /> SIGNED � TITLE 223 <br /> W :PL T PLAN ON RE ERSE SIDE <br /> DEPART NT USE ONLY. <br /> PHASE I <br /> APPLICATION ACCEPTED DATE �D <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/,VINAL INSPECTION <br /> ' INSPECTION BY DATE INSPECTION BY eW DATE <br /> 3/76 2M <br /> �. E H 1426 Rev. 1-74 <br />