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]/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ____... _. <br /> FOE r,OFFICE USE: V 1601 E. Hazelton Ave. , Stockton, .Calif. /fid}° <br /> Telephone: (209) 466-6781 -75`7 <br /> APPLICATION FOR WELL ,CONSTRUCTION OR PUMP PERMIT Permit No. , 53foV/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 9—;475' <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 /> JOB ADDRESS/LOCATION 44 4 " ��! 4V,5�S CENSUS TRACT <br /> Owner's Name ' Phone <br /> Address 4 (,J 7 <br /> �I City 7�/C.t�wc.r _ f... <br /> Contractor's Name {� I <br /> ,..� .-._.__r _-License-4.2 hone h�G-(�f_� 1 <br /> TYPE OF WORK (Check) : NEW WELL gT DEEPEN /? RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION <br /> PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK -= SEWERLINES PIT PRIVY , <br /> SEWAGE'DISPOSAL .FIELD R- CESSPOOL/SEEPAGE PIT i OTHER <br /> PROPERTY LINE _ PRIVATE DOMESTIC WELL PUBLYC DOMESTIC WELL <br /> INTENDED USE _ TYPE OF WELL' - CONSTRUCTION SPECIFYCATIONS <br /> Industrial Cable Too Dia. of Well Excavation r� <br /> Domestic/private Drilled Dia. of Well Casing �r <br /> Domestic/public Driven_ „ <br /> _ Gauge :of Casing <br /> Irrigation Gravel Pack+ Depth of Grout Seal <br /> Cathodic Protection Rotary k Type of Grout � G <br /> Disposal <br /> ;Other Other Information <br /> Geophysical Surface Seal installed B w , <br /> PUMP INSTALLATION.- Contractor - <br /> ` Type of Pump 4 <=-H.P. _ <br /> PUMP REPLACEMENT:_L /_/ ;Stat' Work .Dane � <br /> PUMP '.REPAIR: <br /> /7 State Work. Done <br /> ES;TRUCTION OY WELL: Well Diameter <br /> M Describe Material and Procedure Approximate Depth <br /> I hereby agree'" to comply with all -laws and regulations of the San Joaquin Lo—cal Health District <br /> and the State <br /> .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,Heelth District <br /> WELL DRILLERS REPORT of the well and notify them before putting. the..well in.u96_1-'The above <br /> information is,�true to the best-of my' knowledge and be-lief. I WILL CALL FOR k''GROUT INSPECTION <br /> PRIOR TOG CITING ANDA NTLI, INSPECTION. ; i <br /> SIGNED �- <br /> TITLE <br /> {DRAW PLOT PLAN ON REVERSE SI i <br /> MK-DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY u <br /> ADDITIONAL COMMENTS: DATE <br /> r. - <br /> PHASE Il,,IQROUT INSPECTION) PHASEUI/FINAL INSPECTION)INSPECTION BY DATE o �lli� INSPECTION BY DATE <br /> a <br /> L 'E H 1426 Rev. 1-74 <br />