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SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> ! FORI'OFFICE USE: L 1601 E. Hazelton 'Ave. ,Stockton, Calif. <br /> Telephone: _(209) 466-'6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,cd_ 3 7.Z k) <br /> THIS PERMIT EXPIRES 1 YEAR FROM--DATE ISSUED Issued <br /> (Complete An TriplIcate)_d f 1.t <br /> Application is hereby made to the San Joaquin .Local <br /> .HeathJDiatrict fir a permit to-cohstruct <br /> and/or install the work herein described. This applicati-on,is-made..Yin compliance �with7SaftyJoaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of,•.the: San Joaquin�.Local,Health District. <br /> JOB ADDRESS/LOCATION ; _can ,, • a `n_ CENSUS ;TRACT, _W. F- - <br /> Owner's Name <br /> QPhone <br /> Address 9� ?..:. ._ _ ...._.a.. . ...,... r _ <br /> Contractor's Name Li <br /> .... .._ ..._cense it.2Do ?$ ^one C-0 <br /> tog <br /> i <br /> TYPE OF WORK (Check): NEW WELL '&7 DEEPENL/? RECONDITION /-7 DESTRUCTION <br /> PUMP INSTALLATION &/ PUM /�P REPAIR PUMP..REPLACEIENT - % f <br /> Other /_7 <br /> -- <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PTT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC'WELL ' PUBLIC DOMESTIC WELL S� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS. <br /> Industrial Cable Tool Dia. .of Well Excavation <br /> _ Domestic/private Drilled Dia.• of Well Casing ►: 5" <br /> Domestic/public Driven Gauge of .Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> 2n <br /> Cathodic Protection Rotary Type of .Grout <br /> Disposal Other Other .Information. ., <br /> Geophysics] Surface Seal Installed B t <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump R.P. <br /> PUMP REPLACEMENT: / / State Work Done ' <br /> PUMP .REPAIR: — - <br /> / / State Work Done •• - <br /> ES;TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe <br /> Material and Procedure <br /> I hereby agree to comply with all laws andregulations 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 FINAL INSPECTION. <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: <br /> PHASE II Lft T PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> t E H 3425 Rev. 1-74 <br /> 1-7A ?M <br />