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{ <br /> `SAN JOAQUIN LOCAL HEALTH DISTRICT <br />' E77; <br /> : rf . <br /> Ol E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (20%) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No"I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ' <br /> { (Complete In Triplicate) <br /> 7 <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 Jo4quin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> I JOB ADDRESS/� ,E OJ G© 1Z CENSUS TRACT <br /> i <br /> r Owner's Name �� "f!` /!! Phone <br /> c <br /> Address ! City <br /> Contractor's Name �(, 'a J? S (�� r �c-5 License #,,; dZWAOPhone <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN RECONDITION RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /� <br /> -Other %/ -- <br /> DISTANCE TO NEAREST: SEPTIC TANK , SEWER LINES o a PIT PRIVY 1 <br /> 5. <br /> SEWAGEISP <br /> SAL _IELD CESSPOOL/SEEPAGE PIT OTHER <br /> '. PROPERTY LINES RIVATE DOMESTIC WELLAIW '{PUBLIC DOMESTIC WELL - <br /> INTENDED :USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ' <br /> f'a Cable Tool Dia. of Well. Excavation <br /> Domestic/private Drilled Dia. of Well Casing `dam 1 <br /> Domestic/public 2 Driven Gauge of Casing <br /> Irrigations Gravel Pack Depth of Grout Seal <br /> Cathodic Protection_ <br /> Disposal � � � � ­Othery Type of Grout <br /> Other Information <br /> Geophysical 4 Surface Seal Installed By: <br /> PUMP INSTALLATION:, Contractor <br /> Type of4Pump ! �• .`: H.P. <br /> PUMP REPLACEMENT: / % State Work Done r <br /> PUMP -REPAIR: /7 State .,Work Done <br /> t <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 tlie-."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 GROUTING AND A FINAL INSPECTION, <br /> SIGNED ;z/h <br /> (D P PXAN ON REVERSE SIDE) j <br /> PHASE I <br /> FOR DEP TMENT USE ONLY <br /> ,6 <br /> APPLICATION ACCEPTED ' r DATE -ADDITIONAL COMMENTS:COMMENTS: <br /> PHAS II GROUT INSPECTION PHAS III/FINAL INSPECT ON # <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 : 1/� 7 2M <br />