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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR.`OFFICE USE: 1601 E. Hazelton A e. , Stockton, Calif. <br /> j Telephone : (209)' 466-6781 <br /> p APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7'�-7?3 <br /> 1L1 _ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) _ _ <br /> Application is ht ereby made to the San Joaquin Local Health District for Issued - <br /> / <br /> o �coonstruct <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 /> k <br />` JOB ADDRESS/LOCATION - CENSUS TRACT ` <br /> Owner's Name ---- M <br /> f. Phone <br /> Address f ! <br /> f / City --SfLv C <br /> Contractor's Name <br /> License #j� 1 jphone g <br /> TYPE OF WORK (Check)f% NEW WELL PEN <br /> DEE _ <br /> / / RECONDITION DESTRUCTION <br />` PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT <br /> Oh her /` / j4 I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT PRIVY --- , <br /> 1-N SEWAGE DISPOSAL-FIELD # <br /> CESSPOOL/SEEPAGE PIT�.�-- OTHER <br /> '� 4 PROPERTY LINE i.- <br /> �PRIVA-T-F.DOM&S-T-IC <br /> 1,INTENDED, USE WELL PUBLIC DOMESTIC WELL <br /> TYPE OF WELL �s� . L-'. j CONSTRUCTION SPECIFICATIONS <br /> Industrial '� . <br /> V-) CableI Tool- FDia. of Well Excavation .1i <br /> �C Domestic;/private Drilled <br /> Domestic Dia, of Well Casing 4e <br /> (public Driven <br /> Irrigation ' Gauge of Cabing- - <br /> � 3 Gravel Pack Depth of Grout Seal <br /> Cathodic Protection N Rotary <br /> Disposal �- Type of Grout <br /> r; k�I'! Other Other Information t <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor E <br /> Type of Pump ` <br /> H.P., <br /> PUMP REPLACEMENT: <br /> i <br /> / / State Work Done <br /> PUMP .REPAIR: e <br /> / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> f <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 DA <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Dist rijt 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 b of my knowledge and belief. I WILL CALL FOR A'GROUTIINSPECTION k <br /> PRIOR TO ROU . G AND FIN SPE <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEP TMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE 7 <br /> i <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECT ON r <br /> INSPECTIDN BY INSPECTION BY DATE € <br /> 1 <br /> C\ (,, ,, <br /> E H 1426 --Rev. 1-741 °� 1"`"t <br />