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T SAN JOAQUIN LOCAL HEALTH DISTRICT - - <br /> FOPSiOFFICE USE: 1601 E. Hazelton 'Ave. , Stockton, Calif. - <br /> Telephone: (209) :466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit.No. 7:f�%24V' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE .ISSUED Date'Issued' •,S ' <br /> (Complete In Triplicate) ' <br /> Application is hereby made to the San Joaquin Local Health Disttict .for a permit :to "construct <br /> and/or install the work herein described. This .application is made in compliance with San Joaqui) <br /> County Ordinance No. 1862 and the Rules and Regulations of the _ an Joaquin Local Health District1. <br /> JOB ADDRESS/LOCATION d s ,_ -AVE CENSUS TRACT <br /> Owner°s Name ) Phone <br /> Address 0 .�dE r_ _ . _- City <br /> Contractor's Naive .�_ �,.,_ License. &0;a/0 Phone a.2a <br /> TYPE OF WORK (Check): NEW WELL/-7 DEEPEN J-7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / , PUMP REPAIR 97 PUMP REPLACEMENT fT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK--- SEWER LINES PIT PRIVY <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. <br /> Domestic/private S Diilled� Dia. of Well Casing <br /> =Dom s.tic Jpublic% DrivenY_ " ' .Gauge.-of� Casing <br /> Irrigati- Gravel Pack Depth of Grout. Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophy6ical Surface Seal Installed-BV: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done . <br />"PUMP,.REPAIR:'!"� ' - /�tf S tate`4iork Done �";4L.0d 42 <br /> ;u <br /> ES.TRUCTION OF WELL: Well Diameter A roximate�Depth <br /> PP - <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the Saxe Joaquin Local Health District I <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS r <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 FORA GROUT INSPECTION <br /> PRIOR TO GROU � NG AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> �- - FOR DEPaTMENT USE ONLY ----•- -- — <br /> PHASE I .,._.. t <br /> APPLICATION ACCEPTED BY DATE !�_7_29•_.�� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAAE FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE --7 <br /> 1 E H 1426 Rev. 1-74 1-74 2M <br />,, <br />