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_._.. SAN JOAQUIN LOCAL zHEALTH DISTRICT <br /> FOF9rOFFICE USE: 1601 E. iiazelto£x Ate. , Stockton,, Calif. <br /> Telephone: (209) 466-6781 7"' 1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT 7ermit No. z W <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -.T- <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 /> JOB ADDRESS/LOCATION 4. CENSUS TRACT Oo`7— /00 5,6 <br /> Owner's Name ; Phone y <br /> Address <br /> S _ city 15� <br /> 0,r 7 c 7 9 if i,V <br /> Contractor's Name �,� -i��� L k. k�a_�, 1 License # Phone <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /7 RECONDITION /-T DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR /_7 PUMP REPLACEMENT /7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK tLoot SEWER LINES♦ .4pePIT PRIVY+ .0rar <br />" SEWAGE DISPOSAL FIELD-E.:g,,p r CESSPOOL/SEEPAGE PIT+_2ao.L OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELD'_ "' 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 & <br /> Domestic/public Driven Gauge of Casing WE zez&,� <br /> Irrigation � Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grouts .�, t, Cj <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> i <br /> PUMP INSTALLATION: Contractor i Cr r <br /> Type of Pump i H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,.REPAIR: /? State Work Done _ <br /> ES•TRUCTION 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 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 CALL FOR A GROUT INSPECTION <br /> PRIOR TO (GOINSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> 'OR D)EPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �-� DATE 3 Iq 17 <br /> ADDITIONAL COMMENTS: . <br /> PHASE II GROUT INSPECTION PHASE I INAL INSPECTION <br /> INSPECTION BY DATE 2-77 INSPECTION BY DATE 7 <br /> E H 1426 Rev. 1-74 � 1-74 2M <br />