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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> P34aaEME US&: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;;� 92d <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Z Z-27 <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. 1nd t Rul and Regulation the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION -� M CENSUS TRACT <br /> Owner's NameC Phone <br /> Address City .�. <br /> Contractor's Name License �`'"�' Phone d <br /> TYPEOFWORK (Cheek): NEW WELL X DEEPEN j_-T RECONDITION /-7 DESTRUCTION /j <br /> PUMP INSTALLATION j� PUMP REPAIR 1-7 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 ML - <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br />,, -_ _DAW-stic/pri'vete-- --Dr111-e4- -- - Dia -(Y i el.t"•C.a fij <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:_. it <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: <br /> / / 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 GROUTING AND A FINAL INSPECTION. <br /> ST NED TITLE <br /> "RAW PLOT PLAN ON REVERSE SIDE <br /> v 1.- FOR DEPARTMENT USE ONLY <br /> PHASE I / G <br /> APPLICATION ACCEPTED BY DATE ' �/�'-'�`�G.�_ <br /> ADDITIONAL COMMENTS: <br /> PHASE II QkO , ECTION PHASEII -INSPECTION <br /> INSPECTION BY ATE _ INSPECTION BY r DATE <br /> E H 14 6 1-74 rh/75 2M <br />