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SAN JOAQ�]!N LOCAL HEALTH DISTRICT <br /> FO$rbFFXCE SE: <br /> 1601. E., Hazelton Ave, , 'Stockton, Calif. <br /> telephone: . (209) 466-678.1 <br /> APPLICATION FQR WELL CONSTRUCTION.OR PUMP PERMIT Permit No. 77= s 3 ►!✓� <br /> THIS PERMIT EXPIRES- 1 YEAR FROM DATE ISSUED Date Issued (--' 3-77 <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 Ru'1e6- and Regulations of the San Joaquin Local Health District. <br /> i <br /> JOB ADDRESS/LOCATION V_ ; c.-A CENSUS TRACT j <br /> F <br /> Owner°s Name Phone <br /> Address 2 ,'A «.. City <br /> I <br /> Contractor's.Name.. License # Phone <br /> 1 <br /> TYPE OF WORK (Check): 'NEW`WELL /47 DEEPEN /7 RECONDITION /`7 DESTRUCTION /7 <br /> , ,PUMP INSTALLATION / °/' PUMP REPAIR /7 PUMP' REPLACEMENT /7 I <br /> Other /7 <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 �C Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing jZ- p4 <br /> Domestic/public Driven Gauge of Casing 1-.2--, <br /> Irrigation <br /> -2- <br /> Irrigation Gravel Pack Depth of Grout Seal fd <br /> Cathodic Protection,'-j' Rotary Type of Grout /1. L..� <br /> y` Disposal Other Other Information <br /> _ Geophysical Surface Seal Installed BY: `} <br /> PUMP INSTALLATION: Contractor <br /> 4 Type of Pump% H.P. r <br /> PUMP REPLACEMENT; / / State Work Done <br /> PUMP '.REPAIR:.[,__. /-7 State Work Done = <br /> 4ES1RUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> t <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 CAL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTN AND A FINAL INSPECTION, <br /> SIGNED' TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 3 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIIIFINAL INSPECTI <br /> INSPECTION BY DATE /y -�? '7� INSPECTION BY DATE 7� <br /> .. ^E H 1426 Rev. 1-74 1-74 2M <br />