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' t <br /> I , <br /> SAN JOAQUIN LOCAL HEALTH- DISTRICT f <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton,. Calif. <br /> Telephone: (209),, 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 S` CrJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Sri» <br /> • (Complete In Triplicate) j <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. T cation is made in compliance with San .Joaquin 4 <br /> County Ordinance No. 1862 and the Rules nd Regulations o n Joaquin Local Health District. <br /> { <br /> JOB ADDRESS/LOCATION 5-boo '1V�/1e 1`C-G` CENSUS TRACT <br /> Owner`s Name t-VAt4 �] �1r1 Phone f <br /> Address // City <br /> Contractor's NameA4 (e�h V �(�/ f License �� hone ' <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / / RECONDITION / / DESTRUCTION /-7PUMP INSTALLATION � PUMP REPAIR/ / PUMP REPLACEMENT /� <br /> Other / / — <br /> DISTANCE TO NEAREST: SEPTIC TANK IJ90 SEWER LINESI0TJ J-- PIT PRIVY "` G <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PITA OTHER <br /> PROPERTY LINL-1PRIVATE DOMESTIC WELL,�t`PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF 'WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial • -. Cable Tool Dia. of Well Excavation Z-f <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 2— <br /> Irrigation Gravel. Pack, Depth of Grout Seal _ 4�G _ q <br /> Cathodic Protection _ ' Rotary Type of Grout <br /> Disposal , -~ - Other Other Information i <br /> Geophysical Surface Seal Installed By-:- <br /> V :V ` <br /> PUMP INSTALLATION: �Contractor " s <br /> Type of Pump H.P. '�-- - - <br /> PUMP REPLACEMENT: / /.;, State Work Done <br /> li PUMP .REPAIR: / / State Work Done <br /> DES-TRUCTION 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 <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 F R A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTIO 00 CC J <br /> SIGNED LE <br /> PL-DT, PW 'ON REV'EtSE SIDE is <br /> FOR DEPtRTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �N e�--- DATE s� �J <br /> ADDITIONAL COMMENTS: <br /> PHASE II QROUT INSPECT ON PHAS III/FINAL INSPECTIQN <br /> INSPECTION BY DATE INSPECTION BY DATE a <br /> 7b 2M <br /> E H 1426 Rev. 1-74 QA/ <br />