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" SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF 'OFFICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. JA <br /> Telephone:- (209) 466-6781 / <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 1/o-I& <br /> ,04-77 1 <br /> THIS PERMIT EXPIRES l.YEAR FROM DATE ISSUED Date Issued 1 <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 incompliance with San Joaquin; <br /> County Ordinance No. 1862 and the Rules and, Regulations of, the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �.��,J_ � � '' �,�. . ..,�...� CENSUS TRACT <br /> �v <br /> t . <br /> Owner's. Name � � � Phone � <br /> Address Gt : City ; &A <br /> Contractorts Name 'gooly se # jZLgS_Phone 4:�,7 <br /> 5 <br /> { <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / / RECONDITION /_/ DESTRUCTION /_7 _ <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> l <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY j <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL T <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 D <br /> Irrigation Gravel Pack Depth of Grout Seal_j <br /> Cathodic Protection Rotary Type. of Grout <br /> Disposal Other Other Information <br /> Geophysical. Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ° U <br /> Type of P p H.P. l !. <br /> PUMP REPLACEMENT: / / State Work Done <br /> . 1 <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well. Diameter Approximate Depth <br /> �L 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 A F n ECTION. <br /> SIGNED ��� TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br />'- PHASE I - { <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: s <br /> PHASE II GROUT INSPECTION PHASE III/F NAL INSPECTION <br /> INSPECTION BY fes/ DATE JNSPECTION BY j DATE --Z �7V-' <br /> 7 <br /> 2M <br /> E H 1426 Rev. . l_7 n�77 _ <br />