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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0 ;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ®-- <br /> Telephone (209) 466=6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z7 A) <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 per 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 ad Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> 420�/' <br /> 7--�- i ®�' A9 CENSUSTRACT . <br /> ` e <br /> Owner's Name <br /> Phone <br /> Address Z/ � •��1.,` l' City' <br /> Contractor's Named I <br /> License a hone g�=&kS— I <br /> TYPE OF WORK Check): - -� <br /> ,._,NEW�WELL /+:.�,DEEPEPt�/ - -RECONDITION~/� `DESTRUCTION /�` <br /> PUMP INSTALLATION <br /> :_% PUMP REPAIR'L-7 PUMP REPLACEMENT /7 , <br /> Other/` — # <br /> .DISTANCE TO NEAREST: SEPTIC TANK "SEWER` <br /> Y.INES PIT PRIVY <br /> SEWAGE DISPO AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ! PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED. USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS IndustrialCabl Tool I Dia. of Well Excavation �/�� <br /> Domestic/private Drilled Dia. of Well Casing �� <br /> Domestic/public _ Driven <br /> Irrigation -- 4� <br /> --� ation . � Gauge of Casing <br /> g o Gravel PackDepth of 'Grout Seal <br /> Cathodic Protection Rotary '' Type of Grout : <br /> Disposal .n.�ti r Other Other Information <br /> Geophysical ` <br /> Surface Seal Installed Bv: �A__/_t <br /> PUMP INSTALLATION: Contractor'' ,,�, �, (,(,J R .' E <br /> Type .of Pump �.� <br /> H. <br /> PUMP REPLACEMENT• . <br /> Ll State Work Done <br /> P_UMPREPAIR: State Work Done_` <br /> DESTRUCTION OF WELL: . , Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to eomply with all l:aws `,and regulations of{the` San Joaquin Local Health District <br /> and the State of California `pe'rtaining*,tolor 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 notif them before q <br /> Y putting..the..weil. in.use.... The above <br /> information is true to the-best,of my..knowledge and belief. I WILL CALL FOR A GROUT INSPECTION. <br />?RIOR TO GRO NG AND_ IN ECT N. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I .-� <br /> D E-PART14ENT USE ONLY <br /> APPLICATION ACCEP �- <br /> DATE <br /> ADDITIONAL COMMENTS: -.:• <br /> PHASE II GROUT INSPECTION' . <br /> PHASE I F AL INSPECTIO <br /> LNSPECTION BY DATE <br /> INSPECTION BY DATE -, ' <br /> E .H 1426 Rev. 1-74 �.,.� .... <br />