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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE:OF C,n.A_­uSE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �S-S6of° <br /> THIS PERMIT EXPIRES l YEAR FROM+DATE ISSUED Date -Issued J �� <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. 1662 and .the Rules and Regulations ,of the, San-Joaquin Local Health District. <br /> JOB ADDRESS/LOCATigN S �� �� �� -S'� 6 CENSUS TRACT <br /> Owner's Name o d" S Phone <br /> Address ' N —' z-- s. City ' . <br /> Contractor's Name /l/ _-& v License / �ZL3 Phone 6 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/-7 RECONDITION /-7 DESTRUCTION f7 1 <br /> PUMP INSTALLATION /% --PUMP REPAIR /� PUMP REPLACEMENT f-7 <br /> �. Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 1 _ 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 X Drilled Dia. of Well Casing • H° <br /> Domestic/public. Driven Gauge of Casing <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: Contractor <br /> Type .of Pump we'' r H.P. ' O <br /> PUMP REPLACEMENT: ., '/ / State Work Done ' <br /> PUMP '.REPAIR: / / State Work Done + ' �. ft ton2l'tjr <br /> DESTRUCTION OF WELL Well Diameter � 1Approximate 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 /> land 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 af- my kno led:g and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL XN8TZDnON r <br /> SIGNED , TITLE <br /> PLAN ON ERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> MPLICATION' ACCEPTED <br /> ASE I <br /> BY DATE 1` /L _ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> ' INSPECTION BY DATE INSPECTION BY � . . DATE /77/_ <br /> R 14 1L26 Rebir_ 7-74 <br />