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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFx;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued <br /> (Complete In <br /> Application is hereby made to the San Joaquin oc 1 HTriplicate) <br /> Health District <br /> . a permit <br /> and/or install the work herein described. This. application is made inrcompliancetwithnSan uJoaquin <br /> County Ordinance No. 1$6and the Rules and Regulations of the San Joaquin Local Health District. <br /> ' JOB ADDRESS/WCATION <br /> t <br /> . CENSUS TRACT <br /> .Owner's,Name o 1 4/ 17 ®Z <br /> �-k-� Phone <br /> Addresses O <br /> city , <br /> Contractor's Name,� � � 'f- License #Z Z"57 Phone*?3?1 <br /> TYPE OF WORK (Check): NEW WELL /'7 DEEPEN '/_7 RECONDITION /7 DESTRUCTIO <br /> PUMP INSTALLATION / / PUMP REPAIR /_7PUMP REPLACEME <br /> Other j/_7 <br /> 'DISTANCE TO NEAREST: SEPTICITANK SEWS LINES Sod t PIT PRIVY <br /> SEWAGE `DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> Industrial <br /> IUSE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> l iaCable Tool Dia. of Well Excavation <br /> Domestic/private i Drilled Dia. of Well Casing 77- <br /> Domestic/public Driven Gauge of Casing , <br /> -, IrrigationI Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 1 Rotary _ Type of Grout <br /> Disposal . i Other Other Information ' ' <br /> Geophysical ' <br /> f <br /> Surace Seal InstalledB . <br /> F� Y:' <br /> PUMP INSTALLATION: Contractor 6-A4 e_ <br /> Type .of Pump <br /> H.P. . <br /> PUMP REPLACEMENT / / State Work Donee <br /> PUMP .REPAIR: <br /> / :State Work Done jA, C <br /> DESTRUCTION OF WELL: Well Diameter 12 Af <br /> Describe Material and Procedure Appro- ,�i®e Depth7 ;, <br /> %S %Nd ' <br /> F hereby agree to comply with all laws and regulatiDistrict ons of the Saaquin Local Health <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 .wel]. in.use.. . The above <br /> information is true to the,best.of my knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br />'SIGNED —4 <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FORD PARTMENT USE ONLY <br />!&-PLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE If GROUT INSPECTION <br /> INSPECTION BY PHASE III FINAL INSPECTION <br /> DATE INSPECTION BY DATE S/4/.->y <br /> 1-74 <br /> E H 1426 Rev. Y G I� <br />