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' _ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> `u Telephone: (209) 466-6781 `' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7� y� <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 o. 1862 and the Rules and R�kfff <br /> 1 tion�f the San Joaquin Local Health District. <br /> 2Z�/�-"JOB ADDRESS/LOCATION I@ an 0`4) bkck CENSUS TRACT <br /> Owner's Name L7 1 bed 6. Phone e3y-- SY <br /> Address City e, <br /> Contractor's Name +aS License #-.!AS"7,$3"Phone 1;y <br /> / `79 <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_/ RECONDITION /-7 DESTRUCTION /-7 <br /> AL <br /> \' PUMP INSTLATION/ PUMP REPAIR / / PUMP REPLACEMENT— <br /> Other <br /> EPLACEMENT (V <br /> }( <br /> '\ Other Ll <br /> DIS ANCE 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 X 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 Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump SL aet P S H.P. / <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: 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 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 INSPECTION <br /> PRIOR TO GRO TING AND A FINAL INSPECTION. <br /> SIGNEDTITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE J 7 f <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA E IIY/FINAJ, INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ;r�O <br /> , 1 '77 <br /> - - E H 1426 Rev. 1-74 �`�/� 0'� 7 <br />