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� f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: � 1601 E. Hazelton Ave. , Stockton, Calif. r a <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7'�S61J <br /> THIS PERMIT EXPIRES I 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 <br /> the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 0 d CENSUS TRACT <br /> Owner's Name Phone <br /> Address C City G� <br /> Contractor Is Name ALicense Phone r� J <br /> TYPE OF WORK (Check) : NEW WELL _/;V DEEPEN%/ RECONDITION /_/ DESTRUCTION 4 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE -TO NEAREST: SEPTIC TANK 75 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 <br /> Domestic/private P/rrilled Dia. of Well Casing. <br /> Domestic/public Driven Gauge of Casing _ <br /> Irrigation Gravel Pack -Depth of Grout Seal,' �G <br /> Cathodic Protection otary; _ Type�a.f Grout__ <br /> Disposal ____ :.Other. �, f> " Other Information <br /> -----Geophysical---^` 4T - T--— Surface Sedl- Installed By: 4x�� <br /> PUMP INSTALLATION: Contractor ? t <br /> Type of Pump ,7-1 - �, H.P. �I , <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP REPAIR: � /�/ St 'te W�,/o+rk LC, <br /> Done <br /> " �J/✓ <br /> oed <br /> ES=TRUCTION OF WELL:;`4 Well\Diameteram� TAp�roxa to ITepth <br /> Descr' e - �P_roced'u-rew...,_. - <br /> I hereby agree to comply with all laws and regulat'roMy6o 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 wellin 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 GROUTIN AND A ,FINAL INSPECTION. <br /> SIGNEDt. � _ ITLE ,.,,. ..: .: ,. <br /> (DRAW PLOT PLAN ON REVERSE\SIDE) * <br /> FOR DEPARTMENT USE ONLY" -A,7 <br /> PHASE I ' DAT _� �(' �""r <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONPHAS III/F NAL INSPECTION <br /> INSPECTION BY DATE i3 INSPECTION BY DATE <br /> 1 tip.W � - ` ,...s� T: /z /77 w <br /> E H 1426 Rev. 1-74 56 — � J 6'/7 '] ' , ` �/7� =J <br />