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r. w <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '77%6� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 CENSUS TRACT <br /> Owner's Name vts'-�.1-� ��y� �i Phone � 6 `_,/S-/ <br /> J <br /> Address � ./� �,r ' <br /> City <br /> Contractor's <br /> Contractor's Name 'F-" 001&IV& Al License Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL X DEEPEN / / RECONDITION /_/ DESTRUCTION /_ _ <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / �- <br /> DISTANCE TO NEAREST: SEPTIC TANK '-7W)' SEWER LINES "/Q2.7 PIT PRIVY <br /> SEWAGE DISPOSAL. FIELD CESSPOOL/5EEP,AGE .-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 /C;� � <br /> Domestic/public Driven Gauge of Casing /lam Q <br /> Irrigation Gravel Pack ' Depth of Grout Seal <br /> Cathodic Protection X_ Rotary Type of Grout /3 <br /> Disposal Other. Other Information <br /> Geophysical Surface Seal Installed By: (V(_- <br />.PUMP <br /> fes.PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ' <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 <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 G TING AND �FNAAL�� <br /> SIGNED .� TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -. ` DATE <br /> ADDITIONAL COMMENTS: - <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTIONr L <br /> INSPECTION BY DATE INSPECTION BY 7DATE <br /> T N lfl9h ID— 1 7i. n�l7 nna <br />