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f <br /> 9 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOBtOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. - F-4OO <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued jLy _ <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. Y <br /> JOB ADDRESS/LOCATION DY1� jr. . �- , 1d ''CENSUS TRACT <br /> op <br /> Owner's Name a Gtr • /,Q Phone ' 1 <br /> Address , -4K y City y C <br /> Contractor's Name License Phone .2 S= 3 7 <br /> TYPE OF WORK (Check): NEW WELL ,/? DEEPEN /-7 RECONDITION /7 DESTRUCTION /-7 �I <br /> PUMP INSTALLATION / / PUMP REPAIR /-7-PUMP REPLACEMENT % 7 4f1 <br /> Other j/7 � (" <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVYI <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 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /7 State Work Done _ <br /> ES-TRUCTION OF WELL: Well Diameter Approximate Depth 600 <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 Realth District a <br /> WELL DRILLERS REPORT of the well and notify them before sitting the-well in .use.. The above <br /> informations is true to the best of- my knowledge and be ef. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING A FI AL INSPECTION- <br /> SIGNED TITLE <br /> D 0 VERSE SIDE , <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I r <br /> - •.ICATION ACCEPTED BY <br /> DATE <br /> � �_ <br /> '--,')NAL COMMENTS <br /> €. PHASE II GROUT INSPECTIONPHASE TIT FINAL INSPECTION <br /> 'ON BY DATE TNSPECTION, BY DATE <br /> 426 Rev. 1-74 <br />