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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0TZFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> 00 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7j�__170 <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 of the San Joaquin Local Health District. <br /> JOB ADDRESS/09@NPM 7 CENSUS TRACT <br /> Owner's Name G.. D!:L ! /LQ/fel dt ,S Phone <br /> Address City <br /> Contractor's Name4&)QVeftdAA1.9&1 <br /> License 64K "Phone <br /> TYPE OF WORK (Check): NEW WELL.*/Y DEEP /7 RECONDITION /? DESTRUCTION /7 <br /> PUMP INSTALLATION � PUMP REPAIR /? PUMP REPLACEMENT /7 .ice <br /> Other /7 1 <br /> DISTANCE TO NEAREST: SEPTIC TAN SEWER LINES �g PIT PRIVY i <br /> SEWAGE DISPOSnh IELD oo--- CESSPOOL/SEEPAGE PIT,j;IP A-OTHER— <br /> PROPERTY LINE 7zSP IVATE DOMESTIC WELLZjr_0_'V"PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation /Z <br /> XX <br /> Domestic/private Drilled Dia. of Well Casing f T <br /> Domestic/public Driven Gauge of Casing /2 <br /> Irrigation Gravel Pack Depth of Grout Seal e 16 _ <br /> Cathodic Protection , Y Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> LUMP .REPAIR: /7 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 GROUTING AND A FINAL INSPECTIO . <br /> SIGNED If AW _LE <br /> /'�-- <br /> PIM-ONREVERSE SIDE <br /> AWj <br /> FOR DEPART MEN T USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE , <br /> ADDITIONAL COMMENTS: <br /> PHASE U GROUT INSPECTION P S I FINAL INSPECTION <br /> INSPECTION By <br /> .v DATE I_Vj S INSPECTION BY DATE <br /> E H 1426 Rev. 1-744/75 <br /> 2'P <br />