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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F_0K'OFFICE USE: 1601 E. Hazelton .Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76-7P&) <br /> -THIS PERMIT EXPIRES I YEAR FROM ]ATE ISSUED Date Issued 3-,245� <br /> (Complete In Triplicate) <br /> Application is1iereby 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 Saar Joaquin Local Health District. ' <br /> .TOB ADDRESS/LOCATION . L . CENSUS TRACT <br /> Owner's Name Phone <br /> AddressA,57ZCity , ler& <br /> { t <br /> 'Contractor's Name 4 r License ` _J'Phone =J <br /> t <br /> TYPE OF WORK (Check): NEW WELL '13, r" DEEPEN '/-7 RECONDITION rT DESTRUCTION f7 <br /> PUMP INSTALLATION, 'PUMP REPAIR/_ PUMP REPLACEMENT} /-7 <br /> Other /7—/ <br /> DISTANCF TO NEST: SEPTIC TANK SEWER LINES.'.i < 'PIT PRIVY <br /> eye_ -YSEWAGE-DI$ OS -FIELD'Y�"#'� � CES SPOOL/SEEPAGE+PIT OTHER <br /> PROPERTY. LINE - PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL <br /> INTENDED USE ..TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial v' /Cable Tool Dia. of Well Excavation _�V�/e/ <br /> Domestic/private Drilled - Dia. of Well Ca,`siiag <br /> Domestic/public Driven Gauge. of Casing.. <br /> rigation Gravel Pack Depth ofkGrout Seal „k <br /> Cathodic Protection ; Rotary. _ Type of Grout F <br /> Disposal ' a Other,., Other Information <br /> Geophysical Surface Seal Installed 8 <br /> PUMP INSTALLATION: Contractor Q r <br /> -221 <br /> Type of;! Pump i H.P. /,57 <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP '.REPAIR: / f State Work Done C` <br /> l` <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'Sari-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 /> 3PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATEQ <br /> ADDITIONAL COMMENTS: <br /> PHASE Ii- GROUT- INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 7 <br /> 4 <br /> E R 14'26 ReU. 144 <br />