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-' SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOE OFFICE USE: � 1601 E. Hazelton Ave. , Stockton, Calif. <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 j�;//7 6 <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. <br /> JOB ADDRESS/LOCATION !�� Ji CENSUS TRACT <br /> Owner's Name ` J" Q 7\,l l '� Phone ' <br /> Address / \ City "�f'`<W <br /> Contractor's Name s License ` 3Phone 27Lg <br /> TYPE OF WORK (Check) :� NEW WELL / / DEEPEN / / RECONDITION DESTRUCTION DESTRUCTION /7 <br /> PUMP INSTALLATION/ / 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 �l <br /> Domestic/private Drilled Dia. of Well Casing p <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_:___ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: "State Work Do z � ` <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 w <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 /ten ,�„�,- TITLE 7i j <br /> ---!7DRAW PLOT PLAN ON REVERSE SIDE �-� 177,T <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I n. <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE TI/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY N DATEr ' ? <br /> i <br /> x 3/76 2rkD <br /> E H 1426 Rev. 1-74 r. <br />