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SAN JOAQUIN LOCAL HEALTH DISTRICT <br />` <br /> FOE.;OFFICE USE: <br /> '1601 E. Hazelton Ave. , Stockton, Calif. <br /> ] `� Telephone: . (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76� 3y� <br /> . . — �8 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE"ISSUED Date Issued <br /> I. , (Complete. In Triplicate) <br /> Application is hereby made to the San Joaquin Local IIlealth. 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 J - �, <br /> S' CENSUS, TRACT <br /> Owner's Name O Phone ' 8 $� , <br /> Address „ - <br /> City` iSC �' <br /> Contractor's Name r ,� <br /> License Phone <br /> r <br /> TYPE OF WORK (Check): ° NEW WELL '/ DEEPEN / RECONDITION /7 ,DESTRUCTION /..j <br /> PUMP INSTALLATION -/_/,7P UMP REPAIR /�` tPUMP REPLACEMENT j� <br /> Other 1 / ... .�,_ <br /> DISTANCE TO NEAREST: 1 SEPT iC TANKSEWER LINES: PIT PRIVY <br /> SEWAGE DISPOSAL FIELD - t_.-! CESSPOOL/SEEPAGE PIT OTHER <br /> `-'PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WE <br /> INTENDED USE TYPE OF WELL LL <br /> IndCONSTRUCTION SPECIFICATIONS <br /> ustria]. _ Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven <br /> Gauge, of Casing <br /> Irrigations°� i , ` -.:. �y�,,. ... � n g <br /> Gravel Pack Deptf'f6f Grout .Seal <br /> Cathodic Protection i . :Rotary Type ;of Grout <br /> —Disposal -- ,, �,.._._s_: <br /> + Other <br /> GeophysicalOthe`rrinformation <br /> `- <br /> Surface Seal 'Installed B : <br /> PUMP INSTALLATION: Contractor % E <br /> Type .of Pump <br /> H.P. . <br /> PUMP REPLACEMENT: a 'State Work Done ` V <br /> PU. , <br /> MP REPAIR ,. w /7 `' �. = ^ �. ... -. ... ._ <br /> _ �. State Work ane �...`.. . <br /> DESzTRUCTION OF WELL: Well. Diameter `s N. j1A -� <br /> Describe Material and Procedure i.APproximate Depth <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and 'ihe 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 GRflUTI ANDA N INSPECTION. <br /> SIGNED <br /> TITLE - <br /> DRAW PLOT PLAN QN REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED,.B_Y DATE <br /> ADDITIONAL .COMMENTS: t <br /> PHASE II GROUT INSPECTION PHA I :F. AL INSPECT 0 <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E-;•H. 1426 Rev. 1-74 _ <br /> J'- <br />