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a.+ A__-SAN JOAQUIN LOCAL .FEALTH DISTRICT / <br /> FOR OFFICE USE: •- 1601. E. Hazelton Ave,',. Stockton, Calif. <br /> Telephone : (209) 466-6781 r�J <br /> APPLICATION FOR"WELL CONSTRUCTION OR PUMP PERMIT Permit- No. -7 '1 // <br /> 6) <br /> THIS .PERMIT EXPIRES .1 YEAR.FROM DATE ISSUED Date -Issued <br /> } (Complete ,ln .Tripl,icate') . <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 nd Regul.' tians of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIO ]` CENSUS TRACT <br /> Owner's Name - Phone �-� ( 1 <br /> Address !; �. L City <br /> Contractor s Name ` License #ajkaC1CjPhone <br /> TYPE OF WORK <br /> . (Check) : NEW WELL / DEEPEN / / RECONDITION /T/ DESTRUCTION /-7 _W <br /> PUMP INST LATION / / PUMP REPAIR / /- -PUMP ;REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES)i-'Q00PIT PRIVY <br /> SEWAGE ,DISP SAL FIELDl CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINT id PRIVATE DOMESTIC WF..LL PCJBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation _ s <br /> Domestic/private Drilled Dia, of Well Casing r% <br /> Domestic/public I Driven � ,,, Gauge of Casing <br /> �. <br /> Irrigation.. ., i Gravel Pack Depth.`of Grout Se <br /> al "`'° <br /> Cathodic Protection V Rotary � Type'of Grout <br /> Disposal Other Other Information <br />_ �GedphysicalSurface Sealelnstalled B <br /> 17 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump : r ` H.P. <. <br /> r PUMP REPLACEMENT: / / Sjtate Mork Done <br /> PUMP -REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter t Approximate Deptt: <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- thewell in use.. The above r <br /> information is true to the best of my knowledge and belief. I WILl, -CAL-L-FOR A'GROUT INSPECTION <br /> PRIOR TO GROUTIN D FI ALINSPECTION.. <br /> SIGNED / , TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR PARTMENT USE ONLY --�` <br /> PHASE (- <br /> APPLICATION ACCEPTED BY - DATE <br /> ADDITIONAL COMMENTS: y <br /> PHASE II GROUT INSPECTION PHASE .IIIJFINAL INSPECTION" <br /> INSPECTION BY DATE f7 ., 2f)-'� '' INSPECTION BY �%� DATE '7 <br /> E H 1426Rev. � 1-74 <. <br /> 0, 77 _ '2M <br />