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La°' /l SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE .9FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone:. p (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 �9S <br /> CuS .s�c�-►- v O'e, THIS PERMIT EXPIRES t' YEAR FROM DATE ISSUED Date Issued <br /> (Complete -In Triplicate) <br /> u (( <br /> APlication��is..,.hereb.y;�iade�.tb the San Joaquin Local Health District for a permit to construct <br /> and/or instal ' 'the.:work here&in 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 a" o� O (�/ �Gr CENSUS TRACT <br /> Owner's Name <br /> dr- . . Phone <br /> Address CG x!/.b City (/yL.� <br /> Contractor's Name c•« License #/ ?i Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL /-7" DEEPEN '/- // "RiCONDITION / / DESTRUCTION /7 h <br /> ' h <br /> PUMP INSTALLATION / / PUNP: REPAIR j -PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <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 /> )[ Domestic./private Drilled Dia., of Well Casing Q <br /> Domestic/public Driven - Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary.-. Type of Grout <br /> Disposal Other Other Information <br /> Geophysical' Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 5�1 H.P. f <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP REPAIR: / State Work Done° <br /> DESTRUCTION 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 "i <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 kn led e elief, I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTT AND A FINAL INS M. <br /> �. <br /> SIGNED __TLE , <br /> 15'DRAW. T P AN 'ON RE SSE SIDE) <br /> R DEPARTMENT USE ONLY , <br /> PHASE I ; <br /> APPLICATION ACCEPTED BY ?j <br /> DATE /0 -,7,l- <br /> ADDITIONAL <br /> 7`ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION.- <br /> INSPECTION BY DATE / INSPECTION BY �/� DATE/0- <br /> E <br /> ATE/0-E H 1426 Rev.. 1-74 3/76 2M <br />