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SCA � SAN JOAQUIN LOCAL- HEALTH- DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ` Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No: -znq `.o <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /per?5=76 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct i <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 Son Joaquin Local Health District.'' <br /> / I <br /> JOB ADDRESS/LOCATION ! .d CENSUS TRACT <br /> Owner's Name Phone <br /> I• 9f�Z-%7�� I <br /> Address � � �Q _ City <br /> Contractors Name License �E1)16Q Phone <br /> i <br /> TYPE OF WORK (Check): NEW WELL/ / DEEPEN %/ RECONDITION /_� DESTRUCTION /� <br /> PUMP INSTALLATION/ '/ PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 Drilled Dia, of Well Casing p j <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal g <br /> Cathodic Protection Rotary `+r Type of Grout <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed By: <br /> d` r <br />,,. PUMP INSTALLATION: Contractor <br />: - t Type of Pump_ f H.P. <br /> PUMP REPLACEMENT: / / State:-Work Do` <br /> PUMP .REPAIR: / / State Work Done j <br /> g <br /> DES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby ,ag-ree-.to_comply_with,_all .laws .and,-regulatio;is ,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 j <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 C OR A GROUT INSPECTION <br /> PRIOR T0, OUTING AND FINAL IN PE ION. <br /> SIGNED TITLE <br /> DRAW T TPLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE,IGROUT INSPECTION PLIOVIII/FIVAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE-1 <br /> IV- <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 ; 1 <br />