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SAN JOAQUIN LOCAL HEALTH DISTRICT <br />.;. FOR. OFFICE USE: 1601 E. Hazelton Ave., , ,Stockton, Calif. <br /> Telephone: (209) •466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION -OR PUMP PERMIT Permit No. 7,7- <br /> THIS <br /> -THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> ,Application is $ereby '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. <br /> JOB ADDRESS/LOCATION CENSUS TRACT , <br />' Owner's Name f 6t UC <br /> . , Phone <br />=Address <br /> city , .�°e_ <br /> E L- � '"' <br /> Contractor's Name License �� G G0z Phone <br /> - -- - - - - i <br />-TYPE OF WORK (Check) : NEW WELL DEEPEN%/ RECONDITION /_7 DESTRUCTION /7 <br /> I` PUMP INST LATION / / PUMP REPAIR / / PUMP REPLACEMENT /-J V <br /> ii Other <br />•DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 7PIT PRIVY } <br /> j SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> k; PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> f3 Industrial _ Cable Tool Dia, of Well Excavation <br /> .0 Domestic/private .' : Drilleld. Dia; of Well- Casing _. <br /> Domestic/public Driven' Gauge of Casing <br /> Irrigation Gravel Pack -' - Depth of Grout Seal # <br /> Cathodic Protectioni r� Rotary Type of Grout ° +� <br /> Disposal. Other Other Information "1 <br /> = r3 <br /> Geophysical Surface Seal Installed B <br /> -. I <br /> PUMP. INSTALLATION: Contractor <br /> I9 _ - -- Type of Pump H.P. ..f - <br /> PUMP REPLACEMENT: '. <br /> State Work Done <br />,PUMP .REPAIR: / / State Work Done <br />.DES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> T hereby agree to comply with all laws and regulations of the San Joaquin Local Health istrict <br /> and1the 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 TOLRPUTJNG AND A FINAL INSPECTION. <br />'SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEP NT USE ONLY ? <br />.PHASE I <br />',APPLICATION ACCEPTED-BY ATE :` f �` -22 <br /> ADDITIONAL COMMENTS: <br /> it PHASE II GROUT INSPECTION P NAL INSPECTIO <br />'INSPECTION BY DATE INSPECTION BY DATE /471'? <br /> ii <br /> E <br /> 7 <br /> H 1426 Rev. 1-74 1/ 7 2M , <br />