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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOAOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 46676781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 75= 4t _. _74_-/ <br /> THIS PERMIT EXPIRES 1 YEAR- FROM DATE ISSUED Date Issued �, U__Z� { <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 tate 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 /> /� P5�3s: ; <br /> JOB ADDRESS/TION .', Q '. �/ - CENSUS TRACT 2-70--67 <br /> Owner's Name ^ ' �/ / '�' Phone S <br /> -Address - - <br /> City. s% %� Il1v'f C1',�sf <br /> s <br /> r ' <br /> Contractor's NameC . License #A52 9 Phone .�f E� <br /> 'TYPE OF WORK (Cheek): NEW WELL '/DEEPEN "/7 RECONDITION 1-7 DESTRUCTION /—f <br /> PUMP INSTALLATION PUMP REPAIR -%f <br /> 7' /_7 PUMP REPLACEMENT <br /> Other L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK 7y--7- SEWER LINES okN,9-r PIT PRIVY <br /> SEWAGE DISPOSAL FILLD W CESSPOOL,/SEEPAGE PIT OTHER <br /> DOM <br /> PROPERTY LINE - PRIVATE ESTIC 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 ... -t —Gauge--of-Casing <br /> =_--Tirrigation . Gravel Pack Depth of Grout Sealer --_ <br /> Cathodic Protection-� Rotary Type of Grout - C �8� <br /> Disposal � .� <br /> OtherOther Information <br /> Geophysical. _ �_~j Surface Seal Installed By: r` <br /> PUMP INSTALLATION: Contractor :;9 <br /> 6<,of of Putap - H.P. <br /> PUMP REPLACEMENT: T /77 State Work Done <br /> PU1�REPAIR:.. �x�:- :L"7`w State Work Done <br /> • —' Yom. -"' � s <br /> ES-TRUCTION' OF -WELL: -Well-Diameter <br /> Z:i - ApproxitQate Depth <br /> Describe Material and Procedure' 's"{ <br /> Y <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 tmy 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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE - <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT.USE ONLY <br /> PHASE I ;. <br /> N �LICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ' <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY r DATE _fl _d� yS..._ INSPECTION' BY DATE ' <br /> N4, <br /> E H 1426 Rev. 1-74 <br /> 1-74 2M <br />