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7 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 7FORiOFFICE SE:E: 1601 E. 'Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;. -L 7 <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 f the San Joaquin Local Health District. <br /> &)efl A�af y2/c, -7294 <br /> JOB AD�/LOCATION ,�� .�.�� v- f .s� ,�s 1rcr CENSUS TRACT v�l <br /> 11 T' <br /> Owner's Name o� • F . I^o U Phone <br /> Address C22 !/ ` ellt�r m /fs ,e,' City °fid /" <br /> Contractor's Name o," License # /,937 hone .V6-A` <br /> TYPE OF WORK (Check): NEW WELL L? DEEPEN/_T RECONDITION /? DESTRUCTION /_T <br /> n <br /> PUMP INSTALLATION �� PUMP REPAIR L� PUMP REPLACEMENT f <br /> Other /7 <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 /> _ L Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump .v r H.P. i t'• <br /> PUMP REPLACEMENT: „L/ State Work Done <br /> PUMP :REPAIR: �� State Work Done GSA <br /> 2ES�TRUCTION OF WELLS Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I 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 bef putting the well in use.. The above <br /> information is true to the-best of 1 ge "and b ief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO ING AND A FINAL INSPE ION. 77 <br /> SIGNED E <br /> T PLAN ON REVOW SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I C <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III I SPECT1011 <br /> INSPECTION BY DATE INSPECTION BY ATE <br /> E H 1426 Rev. 1-74 1-74 2M <br />