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SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209)466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 4/7_ZYo <br /> THIS PERMIT EXPIRES]. YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate} x <br /> Application is hereby made to-the San Joaquin Local Health District for a permit to construct <br /> and/or install the work:1herein 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 /> JOB ADDRESS/LOCATION � � � 1`7 CENSUS-TRACT <br /> 57 <br /> Owner's Name �"�T' / �a} 1�'T� l � Phone7 / <br /> Address <br /> Contractor's Name U � License g� 73 Phone <br /> r <br /> TYPE OF WORK (Check) . NEW WELL/ / DEEPEN /% RECONDITION /_ DESTRUCTION /_7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR /_/ PUMP REPLACEMENT <br /> R• <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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS:; <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> . Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal ! OtherOther 'Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP 'INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / State Work Done <br /> PUMP .REPAIR: /r// State Work Done <br /> DES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to complyEwith 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 INSPECT <br /> PRIOR TOG UTING AND FINAL INSPECTION. <br /> SIGNED TITLE { <br /> DACW:PMT PLAN ON REVERSE SIRE) i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �` r <br /> APPLICATION ACCEPTED BY 'p Ise DATE "i�a'91 <br /> ADDITIONAL COMMENTS: <br /> b - PHASE II GROUT -INSPECTION PHAS III/FINAL INSPECTION <br /> INSPECTION BY 1 DATE INSPECTION BY DATE _ • <br /> E H 1426 Rev. '1-74 �? C3/76 2M <br />