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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 05, OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 7-35/5 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .,. �7 7 <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 ,sr"S. "� -i CENSUS TRACT <br /> Owners Name Phone <br /> Address t�� City Contractor's Name .� License �����a�/O Fhone '' <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION DESTRUCTION <br /> PUMP INSTALLATION PUMA REPAIR / / PUMP REPLACEMENT /_7 <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 Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal• Installed By: <br /> PUMP INSTALLATION: Contractor' -1 <br /> Type of Pump V <br /> H.F. <br /> PUMP REPLACEMENT: / / State Work Done�� Cj 04,do <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 DA�lS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Distrfetja <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 CAL FOR A GROUT INSPECTION <br /> PRIOR TO GR UTING APU FIN I SP CTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE - Z3-77 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P /FINa INSPECTION <br /> INSPECTION BY 'DATE INSPECTION BY1j DATE p_� <br /> 1/77 - 2M <br /> E H 1426 Rev. 1-74 <br />