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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOF_.'OFF ICE USE 1601 E. Hazelton Ave. , ,Stockton, Calif, <br /> Telephone: (209) 466--6781 <br /> V 611 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued `3 <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 Joaqutr <br /> County Ordinance ,No. 1862 and the Rules and Regulations of the San Joaquin Local <br /> Health District. <br /> JOB ADDRESS/LOCATION <br /> �! Fa(m l,Ra o c NSUS TRACT' <br /> Owner's Name 1001,Z9Phone ' <br /> 6G <br /> Address Q City - <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check): NEW WELL './—/ N <br /> DEEPEN _ RE - <br /> _ _/� CONDITION /� DESTRUCTION <br /> f PUMP INSTALLATION / / PUMP REPAIR /_/PUMP REPLACEMENT 17 <br /> F Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY .LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL' <br /> 4 INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS' cam <br /> Domestic <br /> # Cable Tool Dia, of Well Excavation <br /> stic/private Drilled Dia. of Well Casing <br /> Domestic/public 7- Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protect16n Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor - <br /> Type of Pump . H.P. <br /> PUMP REPLACEMENT: <br /> / / State Work Done - CIN <br /> PUMP .REPAIR: / / State Work Done <br /> ESJIUCTION OF WELL: Well Diameter r 1 <br /> ,��, � L,11# Approximate Depth- <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health ist;ict <br /> and the -State of California pertaining to or regulating well "construction. Within FIFTEEN DAMS <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 TOG UTING AND A FINAL INSPECTION. <br /> SIGNED <br /> TITLE2zz a=Ags ' <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> F R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: V ` <br /> PHASE I G T INSPECTION PHASE IZI/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYDATR > y o 'T '; <br /> E H 1426 Rev. 1-74 A/77 77: .. [ <br />