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=� a SAN JOAQUIN LOCAL HEALTH DISTRICT �� �( 1 <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> Telephone.: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,7- <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. j <br /> V. <br /> JADDRESS/LOCATION . CENSUS TRACT <br /> Owner's NameP. / t � f � Phone <br /> Address <br /> City , <br /> f <br /> F <br /> Contractor's Name ,, License # Phone <br />-TY-PE­OF-W0"Chet / DEEPEN„'=�_`/-"-RECONIjI-TION-/_T---DESTRUC'fI'ON`y7 T " <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES Al ,_' PIT TRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> f y. PROPERTY LINE - PRIVATE DOMESTIC WELL4; PUBLIC DOMESTIC WELL/1 1_ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS , <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing y' <br /> Domestic/public Driven Gauge of Casing /s::�? ��T, �, ? ,WA° 9L 4.. Q <br /> Irrigation Gravel Pack_ Depth of Grout Seal �$' -Q r �� <br /> Cathodic Protection Rotary *Type of Grout <br /> .�- Disposal Other Other Information , ° v <br /> Geophysical Surface Seal Installed By: E <br /> PUMP INSTALLATION: Contractor t4_ <br /> r/ <br /> Type of Pump . . ?' H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / <br /> State Work Pone., -.-- --' <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 Kan IN ECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) j <br /> FO,- DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHAU II OUT INSPECTI PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE 7INSPECTION BYDATE <br /> -.3♦°79 <br /> UZ7 2M <br /> E H 1426 Rev. 1-74, .. ..: . <br />