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&d 4f SAN JOAQT =.: L AL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2���1`J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued7,7 <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 CENSUS TRACT <br /> Owner's Name / %G c!� _' - /, Phoney; <br /> Address / - � � t �r—. City -'- <br /> Contractor's Name . License , Phone .Z.I <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/li DEEPEN %/ RECONDITION /_-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other <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 f <br /> t - Domestic/private t Drilled Dia. of Well Casing p • <br /> Domestic/public Driven Gauge of Casing ' s" - <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 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 G OUTING AND INAL INS CTIO , <br /> SIGNED401�1 ,, ITLE <br /> "J D • L T' LAN ON RE SE SIDE <br /> FOR DEPARTMENT USE ONLY f <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHAS & II G OUT INSPECTION PHASE ITI/FIN4 INSPECTION <br /> INSPECTION BY / DATE &/7Z INSPECTION BY DATE 2 5 --7 <br /> T <br /> Rev. 1-74 <br /> E H 1426 � . 3/76 2M <br />