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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> �[ <br /> Telephone: (209) 466•-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77#4p 1d <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued x)/_22 <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 />'h JOB ADDRESS/LOCATION / <br /> � fi`�L � CENSUS TRACT ' <br /> Owner's Name <br /> Phone <br /> Address City <br /> Contractor's Name ,., - License #7_44SZ Phone 5-1�,q- Z� <br /> TYPE OF WORK (Check) : NEW WELL /f` . IiEEPEN /% RECONDITION /% DESTRUCTION /_7 <br /> PUMP-,INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT J� <br /> Other`/ / <br /> t <br /> DISTANCE TO NEAREST:`"-SEPTICITANK,-3"o;�f SEWER LINES PIT PRIVY t <br /> # SEWAGE",h18P0SALjFIELD CESSPOOL/SEEPAGE PIT. OTHER <br /> `PROPERTY :LINE, --!PRIVATE DOMESTIC WELL PUBLIC. DOMESTIC WELL <br /> INTENDED USE; TYPE OF'WELL CONSTRUCTION--,SPECIFICATIONS <br /> :Industrial ', --Zv (_.Cable Tool Dia. of Well Excavatibh IAJ ; <br /> Domestic/private Drilled Dia. of Well Casing ,7 <br /> Domestic/public Driven Gauge of Casing ,� C <br /> Irri ation `�: ^� � • <br /> g k Gravel Pack Depth of Grout Seal <br /> :Cathodic Protection} Rotary Type of Grout <br /> Disposal 06er Other Information': a <br /> Ceophysical - ,3', ""` ' —`Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ��� <br /> Type of Pump - =+ H.P. <br /> F _ <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP .REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure E <br /> I hereby agree to comply with all laws and regulati:ons -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-thein before putting the well in use. The aboveinformation e <br /> PRIOR TO GROU s NG lle to D A FINAL sINSpECrI knowledge.and^ �1ief. � 2 WILL GALL FOR A GROUT INSPECTION <br /> 1 <br /> SIGNED TITLE <br /> W ' <br /> FOR DEPARTMENT.--USE- ONLY <br /> PHASE I /q <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: 49 <br /> PHASE II GROUTINSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev,1�74� <br />