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IX SAN JOAQUIN LOCAL. .HEALTH DISTRICT <br /> ToSelOFFICE USE: 1601 E. Hazelton Ave. ,' Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> aAlu APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;;�7/aQ�v <br /> THIS PERMIT EXPIRES 1-YEAR FROM DATE ISSUED Date Issued <br /> k (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 /> I ° <br /> JOB ADDRESS/LOCATION W gn? ,�; CENSUS TRACT <br /> OwnerPs Name - u _ Phone a a <br /> Address . � .. i...,,._.: city .S�ioA-04-j <br /> -r r <br /> Contractor's Name LicensePhone02 "' <br /> TYPE OF WORK (Check): NEWIWELL,�s/7'�DEEPEN 17 RECONDITION /_7 DESTRUCTION /_7 - <br /> �� PUMP INSTALLATION_ / PUMP PAIR,f /..PUMP.u.REPLACEMENT 17 <br /> Other clh! <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESI PIT:.-PRIVY <br /> SEWAGE DISPOSAL FIELD.., CESSPOOL/SEEPAGE PIT OTHER <br /> s* - °P ROPERTY''`LINEf= PRIVATE DOMESTIC WELT! PUBLIC DOMESTIC WELL <br /> ':V. INTENDED ,USE ► TYPE OF 'WELL L :,� t g CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. ,of, Well Casing <br /> Ii <br /> Domestic/public Driven <br /> p 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 SealInstalled By <br /> PUMP INSTALLATION: ' Contiractor <br /> Type of Pump "r H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REP;A;xR:�" ��"��1-tate Work'Done`A <br /> ES;TRUCTION OF WELL: Well Diameter . f �` 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 an a new well, .i will furnish the San Joaquin Local Health District a <br /> p WELL DRILLERS REPORT of the well and notify them before putting-the- well in use.. The above <br /> F informatioit,is -true-to--the;best-of- my knowledge and belief.. I WILL CALL FOR 'A GROUT INSPECTION <br /> PRIOR TO GROUT G ANDA NA INSPECTION. <br /> SIGNED TITLE <br /> E (DRAW PLOT PLAN ON REVERSE SIDE <br /> I M FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE : <br /> ADDITIONAL COMMENTS: <br /> PHASE IA GROUT I SPECTION PHAUJI10INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 14 <br /> .. �. <br /> ' E H 1426 Rev. 1-74 1-74 2M <br />