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FOl '*OFFICE USE: - SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave, , ,Stockton, Calif. / <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Permit, No. 7 7—/�.5> <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued >��� <br /> ( Triplicate <br /> Application is Aereby made to the San (Complete <br /> in Local Halth Distri <br /> and/or install the work herein described. This application is ct for a <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Jo made in compliance with San Joaquin to construct <br /> JOB ADDRESS/LOCATION Joaquin Local Health District, <br /> CENSUS TRACT <br /> Owner's Name v <br /> Address <br /> Phone t <br /> , <br /> CoAtractor's Name City <br /> License # ZLUDPhone <br /> TYPE OF WORK (Check): NEW WELL/ / DEEPEN <br /> PUMP INST / / RECONDITION /� DESTRUCTION /�' <br /> _ I•LATION / / PUMP REPAIR %/ PUMP REI'Lt�CgMENT /-7 <br /> Other /�j <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWAGE DISPOSAL FIELDER LINES PIT PRIVY <br /> PROPERTY LINE - PRIVATE DOMESTIC SW WELL <br /> PIT _ OTHER <br /> INTENDED USE TYPE OF WELL PUBLICMEDO STIC WELL <br /> Industrial Cable Tool CONSTRUCTION SPECIFICATIONS , <br /> Domestic/private Drilled Dia. of Well Excavation <br /> Domestic/public Dia, of Well Casing <br /> Irrigation Driven Gauge of Casing <br /> Cathodic Protection Gravel Pack Depth of Grout Seal <br /> Disposal Rotary Type of Grout <br /> Geophysical Other - Other Information <br /> � Surface Seal <br /> PUMP INSTALLATION: Installed By: <br /> Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT. H.P. <br /> / State Work Done <br /> PUMP :REPAIR: State Work Done <br />)ES•TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> hereby agree to comply with all laws and regulations of the San Joa u <br /> end the State of California pertaining to or regulating well "construction.Lo it <br />.f ter completion of m Health i$tr�ct <br /> y work on a new well, I will furnish the San Joaquin Local hHealtin hTDistrict a <br />'ELL DRILLERS REPORT of the well and notify them before putting. the..well in use. <br /> nformation i$ true to the best of m The above <br /> IIOR TO GROUTING AND A FINAL INSPECTION. and belief. I WILL CALL FOR A GROUT INSPECTION <br /> IGNED �, � . <br /> ^�-�- TITLE I _ <br /> DRAW PLOT PLAN ON REVERSE SIDE) V ""''--- <br /> 11ASE I FOR DEPARTMENT USE ONLY <br />?PLICATION ACCEPTED BY <br />)DITIONAL COMMENTS: DAT$ <br /> PHASE II GROUT INSPECTION <br /> fSPECTION BY DATE PHASE III/FINAL INSPECT N <br /> INSPECTION BY DATE r <br /> E H .1426 Rev. 1-74 <br /> I/77 e.. <br />