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SAN JOAQUIN LOCAL'HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> t, Telephone: (209) 466-6781 <br /> 2j virl APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7J-s1Sj1� <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/LOCATION ( _? -3C. b ; P".-SA; ti �� Y���,,�-�,� CENSUS TRACT <br /> Owner's Name I ( � Co ; p r Phone <br /> Address 1 :] 3 n C5 City lie tor_c.C _ <br /> Contractor's Name �� eri.-t � ( , 4 License # Phoney � <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN %/ RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION /L(/ PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other J / <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 Q <br /> 1t Domestic/private Drilled Dia. of Well Casing 4 <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 �n, �. ,b -� - H.P. <br /> PUMP REPLACEMENT: / / State Work Done r <br /> PUMP .REPAIR: / / State Work Done ` <br /> DESTRUCTION OF WELL: Well Diameter Ot'dProxim a Dept <br /> Describe Material_and _Procedure <br /> I hereby agree to comply with all laws and regulations 6f 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 INSPECTION. <br /> SIGNEDLTITLE se�Qt <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ^� <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PMS /FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION B r <br /> DATE -77 <br /> -�v�— <br /> E H 1426 Rev. 1-74 <br />