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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOk OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. D (i <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued '�lo <br /> (Complete In Triplicate) <br /> Application is Aereby 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 <br /> Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Gt_S{ /Pj CENSUS TRACT <br /> Owner's Name Q/77 Phone <br /> Address r JCSv� ° �C� City ' y T <br /> Contractor's Name �C��it- a )(4g, /✓r•&or J&C License # C( c( f Phone Cp�? l <br /> i <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN%/ RECONDITION / / DESTRUCTION /7 <br /> PUMP INST LATION / / PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK „r SEWER LINYS 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 I(”' , <br /> Domestic/private Drilled Dia. of Well Casing k'l - <br />�_ Domestic/public Driven Gauge of Casing '7 9k 6r 17 <br /> -- <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other �V�ther Information *r100- <br /> Geophysical Surface Seal Installed BY: Oily lk&' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,.REPAIR: / / State Work Done - <br /> DES—TRUCTION 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 /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � J <br /> APPLICATION ACCEPTED BY (� DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> WPT N BY TE •- .- ( I SPECT ON B DATE f y rl — V 1 S J Gt t Q( {3 <br /> E H 1426 ev. 1-7 —7 1/77 2M <br />