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C6� / SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO£�. CE USE: ,1601 E. Hazelton Ave. , Stockton, Calif, <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR 'WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77�Z - j <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <br /> t <br /> (Complete In. Triplicate) , <br /> Application is hereby m�Ae 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 /> JOB ADDRESS/LOCATION ��I.b f ko v CENSUS TRACT <br /> -Owner l s Name �a�r,l�4 � Phone <br /> Address ��� ;1,/ J, �_._ (� City <br /> - . <br /> Contractor'a Name (5_,P/_� � , License # /1.i - - hone ;7 <br /> , <br /> TYPE OF WORK (Check): NEW WELL/ DEEPEN j-7 RECONDITION f_7 DESTRUCTION (7 <br /> PUMP INSTALLATION / (/ PUMP REPAIR I PUMP REPLACEMENT r7 <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 4 PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL \ <br /> INTENDED USE TYPE OF WELL _ _ , CONSTRUCTION SPECIFICATIONS. �} <br /> F, Industrial Cable Tool Dia. ,of Well Excavation - ' <br /> Domestic/private Drilled Dia'. of Well Casing � <br /> Domestic/public Driven _ Gauge of Casing <br /> Irrigation Gravel Pack-,� Depth of Grout Seal <br /> Cathodic Protection Rotary r Type of Grout <br /> -Disposal Other Other Information <br /> k Geophysical Surface Seal Installed B <br /> k r <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump i H.P. / <br /> PUMP State <br /> PUMP -REPAIR: "�/ State Work Done <br /> _ P <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 hereby agree to comply with all laws and regulations of the San, Joaquin Local Health District <br /> and the State of Galifornia' pertaining to or regulating well"construction. Within FIFTEEN DAYS <br /> r 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..well. in.use.... .The above <br /> information is true to the-best of k`r ledge-afid elief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GRO ING -AND A FINAL INSP ION. TITLE /��J'r <br /> SIGNED r' <br /> D PLO LAN ON AVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ! <br /> APPLICATION ACCEPTED BY DATE _- <br /> ADDITIONAL COMMENTS: <br /> .PHASE II GROUT INSPECTION PHASE III/FINAL-INSPECTION <br /> INSPECTION BY DATE INSPECTION BY r' DAT <br /> E S 1426 Rev. 1-74 4/75 <br />