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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOA+0EFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. .c1 <br /> 77- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued X27 <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 Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION / 3y rA CENSUS TRACT <br /> Owner's Name Phone <br /> _ T i <br /> Address /�� �°!- 9��a City .� 1 <br /> Contractor's Name A L TS K A00,C-A License # iD/�;7 Phone <br /> TYPE OF WORK (Check): NEW WELL -7 � T-7 <br /> _ DESTRUCTION /'7 <br /> PUMP INSTALLATION KI PUMP REPAIR /� PUMP REPLACEMEN7C /7 <br /> Other /�7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY �n <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 0.e <br /> Domestic/private Drilled Dia. of Well Casing f� <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> r Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / State Work Done <br /> PUMP '.REPAIR: /7 State Work Done <br /> PES;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 k" ledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT AN A FINAL INSPECTIONJ <br /> SIGNED TITLE <br /> (DRA T PLAN ON REVERSE SIDE <br /> LO <br /> FOR DEPARTMENT USE ONLY <br /> ' PHASE I A,_- <br /> APPLICATION ACCEPTED $Y . DATE . <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 1ti E H 1426 Rev. 1-74 1-74 2M <br />