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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 �'� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 025 `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 thes�ul an Regulatio o the San Joaquin Local Health District. <br /> 61 . <br /> JOB ADDRESS/LOCATION -- z* CENSUS TRACT <br /> Owner's Name Phone <br /> : � � <br /> Address �.:� � ��r,_ -..:_ �----� City�,,!� <br /> Contractor's Name C � � � j"� �1-73Tv� License � JG ' Phone �! <br /> t <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION �-t-' PUMP REPAIR / / PUMP REPLACEMENT <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 <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing G <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 TING AND _.FINAL INSPECTION. <br /> SIGNED ! 4 TITLE _ -)\ L- <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> ,4APPLICATION ACCEPTED BY DATEZa <br /> X7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS I/FI AL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE �2A <br /> E H 1426 Rev- 1-74 <br /> ii f x ! 2M <br />