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SAN JOAQUIN LOCAL 'HEALTH DISTRICT <br /> FO t'OFFICE USE: 1601 E. Hazelton Ave. ' Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-L$a10 I <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- lealth Disttiet 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 S, 1�� CENSUS TRACT <br /> a a Q : h.1 <br /> Phone7D 5� <br /> Owner s Name <br /> Address" Z0City <br /> Contractor's Name Ze f License #4�ara PhoneCf <br /> TYPE OF WORK (Check): . NEW WELL /7 DEEPEN RECONDITION /_T DESTRUCTION f7 <br /> PUMP_INSTALLATION-%/._PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES..__. _. PIT PRIVY <br /> `" '""'"SEWAGE-DISPpSAL FIELD'S <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> 4 PROPERTY LINE - PRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ' '' <br /> Industrial Cable Tool Dia. of Well Excavation Q <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 ry ' -7Surface Seal Installed_BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done 0 Q 4 = g <br /> PUMP i.REPAIR: /7• State Work Done - <br /> PE&TRUCTION OF WELL: Well Diameter Approximate Depth _ <br /> .�-.»•- .-:- <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 GROUTIX AND A ZNAI& INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br />� PHASE I <br /> APPLICATION ACCEPTED BY DATE 3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INS CTION PHASE III NAL INSPECTION <br /> OL <br /> INSPECTION BY DATE INSPECTION BY DATE r <br /> it E B 1426 Rev. 1-74 1-74 2M <br />