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SAN JOAQUIN LOCAL HEALTH DISTRICT } <br /> 70T OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 5 <br /> Telephone: (209) 466 .6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 ^ 71' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued � <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local health District f.or a permit. to construct <br /> and/or install the work herein described. This application is made incompliance with San Joaquin <br /> County Ordinance No. 1862. and the Rules and Regulations of the San 'Joaquin Local Health District. <br /> JOB ADDRE55/LOCATION 1iitn;try CENSUS TRACT <br /> Owner's Name Phone <br /> Y <br /> Address 47 City , 0-ZLZ. <br /> Contractor's Name � License ?Phone-?C <br /> AV <br /> 4 TYPE OF WORK (Check) NEW WELL -/7 DEEPEN '/r/ RECONDITION /� DESTRUCTION <br /> PUMP INSTALLATION"/-7 PUMP REPAIR/_7PUMP REPLACEMENT <br /> Other L-1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> F SEWAGE DISPOSAI3 FIELD CESSPOOL/SEEPAGE PIT' _ OTHER <br /> PROPERTY LINE--4 'PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE. }TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> i Industrial Cable�Tool Dia. of Well Excavation 4 <br /> Domestic/private Drilled Dia. of Well Casing '\ <br /> Domestic/public Driven' Gauge of Casing. <br /> ,=)Irrigation � � Graver Pack � ..Depth of Grout Seal <br /> I 'Cathodic Protection Rotary!L-..T......-A ,, ;Type of Grout <br /> Disposal. - Other \Other Information <br /> Geophysical a ISiifface Seal Installed' 'B <br /> PUMP INS TALIA NTI0 . contr. <br /> -�� on r'• c��•.,'' -- - -- � — �_.... A� � <br /> r ,Type 3f Pump H.P.. s� <br /> PUMP REPLACEMENT: . ` tate Work Done 64, <br /> . <br /> PUMP '.REPAIR: --{ SAE/-7 tate Work Done <br /> ! DESTRUCTION OF WELL: ;.Well. iameter Approximate Depth <br /> Describe Material and Procedure <br /> II hereby agree to comply with;all laws and regulations of the San Joaquin Local Health District <br /> and the State of California ertaining to or regul 'ting well "construction... Within FIFTEEN DAYS <br /> ) after completion of myivork n a. new well., I will furiiish the Sant Joaquin Local Health District a <br /> WELL DRILLERS REPORT ofthe ell and notify them bfore putting the.—well—in—use... The above <br /> information true to`'the-b t of my. kwledge an belief. I WILL CALL. FOR A -GROUT INSPECTION. <br /> PRIOR TO GR NGA D A INSPECT-107 <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: . -Ii ' <br /> a PHASE 11 GROUT INSPECTION PHASE INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - -�G <br /> I E R 1426 Rev. 1--74 -- <br />