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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ' FORIOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. S f0/ed <br /> THIS PERMIT EXPIRES I YEAR FROM,DATE .ISSUED Date .Issued� L <br /> (Complete In Triplicate). <br /> Application is hereby trade 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,.complience with San Joaguink <br /> County Ordinance No.-1862- and the Rules and Regulations of the San...Joaquin Local Health District. <br /> �lTz�_a l� .s. <br /> JOB ADDRESS/LOCATION fIf <br /> . l7" �-�� CENSUS ,TRACT 00'7 ' 2&0-21: <br /> Owner's Name Phone 9 <br /> Address <br /> v-ao•(l . . --.� City._;� „ <br /> Contractor's Name License �arlgy Phone - c1 <br /> TYPE OF WORK (Check): NEW WELLDEEPEN '/_7 RECONDITION /_7 DESTRUCTION /—f <br /> PUMP INSTALLATION 6;� PUMP REPAIR /_7PUMP REPLACEMENT %7 4 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK fSEWER LINES PIT PRIVY <br /> SEWAGE DISPO AL FIELD CESSPOOL/SEEPAGE PIT/ OTHER'. Nt <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 /> �I Domestic/private Drilled Dia.. of Well Casing s _ . <br /> _ Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal, p �{ <br /> Cathodic Protection Rotary Type of.Grout -7- <br /> DisposalOther Other Information <br /> —Geophysical Surface Seal Installed-By: <br /> PUMP INSTALLATION: ContractorIA <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: E7 State Work Done r t <br /> PUMP !REPAIR: A <br /> L7 .State Work Done <br /> ESiRUCTION OF WELL: Well Diameter 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 on a new well,, I will furnish the San Joaquin Local Health District;a <br /> WELL DRILLERS REPORT of t 1 and notify them before putting the- well in-use.. The above <br /> information ie to of m know ge'.and belief. I WILL CALL FOR 'A 'GROUT IN <br /> PRIOR TO GROVTIINAL INSPE <br /> SIGNED TITL <br /> DRAW PLOT PLAN ON.-REVERSE SIDE ; <br /> FOR DEPARTMENT USE ONLY ' <br /> PHASE I 4 <br /> APPLICATION ACCEPTED $Y /' DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE I GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY _ DATE Y <br /> E H 1426 Rev. 1-74 ,_7A IM <br />