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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F FFIC USE: jp 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 1/0, 11 Telephone: (209) 466-6781 <br /> ,;APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> I� THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,2 1x4=77 <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 /> F County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> _ r <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> f16 - <br /> k Owner's Name -- f dL 6 GC-a Phone <br /> I <br /> Address _ il' 6 6L} dA ` ,�P Citya. <br /> t - <br /> Contractor's Name L License # Phone6 <br /> 11 <br /> a v <br /> TYPE OF WORK (Check) ; :NEW'WELL / / DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 <br /> iPUMP INSTALLATION /—/ PUMP REPAIR /a PUMP REPLACEMENT /-T <br /> I� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY M <br /> SEWAGE DISPOSAL FIELD' ' ' <br /> ..= ' -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 /> f _ <br /> Domestic/privatelj Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack 'Depth of Grout Seal <br /> Cathodic Protection Rotary Typo -of Grout <br /> Disposal Oil Other Other Information <br /> Geophysical Surface Seal Installed By <br /> II 4 Y I <br /> PUMP INSTALLATION: !!'Contractor <br /> ilType of Pump H.P. F <br /> PUMP REPLACEMENT: State Work Done ' <br /> s PUMP .REPAIR: / / State Work Done`': :�a - <br /> f II <br /> DES-TRUCTION OF WELL: Well-Diameter s _ Approximate Depth <br /> liDescribe Material and Procedure <br /> . <br /> I hereby agree to compl!ly 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 myMwork 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 thewell in use. The above <br /> information is true to" the pest of my„kno ed a-and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU ING AND A FIN SP TO <br /> SIGNED ITLE <br /> Y} P PAN ON ASE SIDE +' <br /> OR DEPARTMENT USE' ONLY <br /> PHASE I I� <br /> APPLICATION ACCEPTED BY.. DATE <br /> 'ADDITIONAL COMMENTS: <br /> PHASE II R T 4&PgCTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY INSPECTION BY DATE 77 <br /> II <br /> .. . • , <br /> E H 1426 Rev. '1-74 3/76 2m <br />