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V <br /> �. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORIOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> i Telephone: (209) 466-6781 -- � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � {� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -/-J <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 ismade in compliance with San Joaquin <br /> 7 County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health .District. <br /> ' JOB ADDRE11 <br /> SS/LOCATION CENSUS TRACT <br /> Owner's Name 76 ,� Phone <br /> Address -- �.z�F' . 'iQ l S/ ,„ D/ efS7RQ..._,L4- xCity <br />!t Contractor's Name License #.1 Phone <br /> TYPE OFWORK: heck): NEW WELL '/�EEPEN RECONDITION /-7 DESTRUCTION <br /> p,` PUMP INSTALLATION ON REPAIR /7 f <br /> PUMP REPLACEMENT f <br /> Other <br /> �. A <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY .A <br /> . SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -_PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL w <br />` INTENDED USE ` TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> k industrial <br /> able Tool Dia. of Well Excavation <br /> f domestic/private Drilled Dia. of Well Casing <br /> i Domestic/public Driven Gauge of Casing <br /> IrrigationiE Gravel Pack Depth of Grout Seal AF <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical _11 Surface Seal Installed B ' VIg <br /> i <br /> PUMP INSTALLATION: .pContractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State-Work Done ;;'; . <br /> PUMP :REPAIR: <br /> 1/7 State Work Done = '� <br /> tE&TRUCTION OF WELL: well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> f I hereby agree to comply with all laws and regulations of the SankJoaquiniLocal 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 then°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.QgWTjFG AND A'IgIUL INSPECTION. ` <br /> SIGNET} TITLE �® <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> F PRASE I FOR DEPARTMENT USE ONLY <br /> N <br /> k APPLICATION ACCEPTED BY� <br /> DATE <br /> ADDITIONAL COMMENTS: / 2 <br /> PHASE IT 'GROOT INSPECTION •,—f PHASE III FI AL INS] E <br /> k\INSPECTION BY E. DATE INSPECTION BY a DATE <br /> T3 1426 Rev. 1-74 <br /> .L 1-74 2M <br /> lei <br />