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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Cf Stockton Calif . <br /> Ok OF ICE USE: 1601 E. Hazelton Ave. , , <br /> Telephone: (209) 466-6781 permit No. '77`1' sla <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued � �7 7 <br /> (Complete In Triplicate)' <br /> a permit Application is hereby made to the San Joaquin Local <br /> llicalth District made or compliancetwithnSanuJoaquin <br /> and/or install the work Herein described. PP <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District• <br /> CENSUS TRACT i <br /> JOB ADDRESS/LOCATION <br /> IN / Phone <br /> Owner's, Name <br /> ` City <br /> Address <br /> ?6 ?G <br /> II ,d <br /> License # � �7z�] Phone <br /> Contractor's Name <br /> - II <br /> RECONDITION I J DESTRUCTION /7 <br /> I TYPE OF WORK (Check) : NEW WELL ./ I/ DEEPEN I I PUMP REPLACEMENT J� <br /> PUMP INSTALLATION l�'I PUMP REPAIR ./-/-PUMP <br /> I�ther / / <br /> E SEWER LI . IT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC TANK NES CESSPOOL/SEEPAGE PIT OTHER W <br /> SEWAGE DISPOSAL FIELD PUBLIC DOMESTIC WELL <br /> PROPERTY LINE - PRIVATErDOMESTIC WELL CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Drilled Dia. of Well Casing <br /> Domestic/private Driven d Gauge of Casing <br /> Domestic/public --1� <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> � .' Type of Grout <br /> Cathodic Protection Rotary Other Information <br /> Disposal Othexw� -j <br /> _ Surface Seal Installed BV: <br /> Geophysical <br /> k C�� ov <br /> PUMP INSTALLATION: Contractor H. <br /> ;Type of Pump <br /> PUMP REPLACEMENT: / 4 State Work Done d <br /> PUMP REPAIR: /% State Work Done <br /> Approximate Depthl <br /> EDESiRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> I <br /> I hereby. agree to comply with all laws andoreregulating well'construction.t San Joaquin LoWithin aFIFTEEN tDAYS <br /> and the State of California pertaining to g <br /> l after completion of my,work on a new well, Ithemlbefore$h the puttingatheowell- inouse.HeThehabover District a <br /> IWELL DRILLERS REPORT of the well and notify <br /> information is true to the best of my knowled e and belief. I WILL CALL FOR A GROUT INSPECTION <br /> [PRIOR TO GRQU3,,I AND I!A FINAL INSP _ LE -- <br /> SIGNED { P T P ON RE SE SIDE) <br /> OR DEPARTMENT USE ONLY <br /> PHASE I DATE 7 <br /> APPLICATION ACCEPTED BY <br /> - ADDITIONAL COMMENTS: 11 P IJ INAL INSPECTION <br /> PHASE I11GROUT IN PECTION INSPECTION BY DATE <br /> } INSPECTION BY II DATE <br /> 1177 . 2M <br /> R H 1426 Rev. 1174 _ - - <br />