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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> P.rOMICE USE: "` "' 1601 E. Hazelton Ave. , Stockton Calif. <br /> Telephone (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-�„S3V <br /> THIS PERMIT EXPIRES 1 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 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 /> JOE ADDRESS/LOCATION o!� <br /> Ao CENSUS TRACT 4 <br /> Owner"e Name -� .A <br /> ���- Phone <br /> Address <br /> City <br /> Contractor's Name License # aa Phone <br /> TYPE OF WORK (Check): NEW WELL /_ DEEPEN /7 RECONDITION /? DESTRUCTION /_7 <br /> PUMP INSTALLATION/ / PUMP REPAIR :/� PUMP REPLACEMENT /7 <br /> Other /� a <br /> DISTANCE TO NEAREST: SEPTIC TANK 00 SEWER LINES ' PIT PRIVY � <br /> SEWAGE DISPOSAL FIELDCESSPOOL/SEEPAGE PIT OTHER O <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL— PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICA ONS <br /> Industrial Cable Tool Dia. of Well Excavation - V) <br /> V Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing 0 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout ` <br /> Disposal Other Other Information o <br /> Geophysical Surface Seal. Installed By: <br /> PUMP INSTALLATION: Contractor . � ��( <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Donee r <br /> -7-7 <br /> PUMP '.REPAIR ,, <br /> / . :State: Work--Done' <br />)ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> L 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 4 <br /> Lnformation is true to th best.of-my..knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />'RIQR TO GRO NG 'AN A AL INSPECTION. <br /> SIGNED TITLE �. <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br />'RASE I FOR DEPARTMT USE ONLY <br /> IPPLICATION ACCEPTED BY <br /> DATE � �� <br /> WDITIONAL COMMENTS: <br /> F'RAF99A ,GROUT IN SP CTION P I AL INSPECTION <br />[NSPECTION BY DATE 7 INSPECTION BY DATE y � <br /> E H 1426 Rev. 1-74 1.h7e nu , <br />