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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. /* lc ' "l <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -a77 <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, 1.862 and the Rules and Regulations of the San Joaquin Local Health District.' <br /> JOB ADDRESS/LOCATION �,G�it,/ 'fes .• /yr�o�.+ `� CENSUS TRACT <br /> Owner's Name Phone �^ <br /> Address �i? 0 r-� w. ( _...._ City C6-P0.! �. # <br /> Contractor's Name License #J 13,73 Phone-3E, �� <br /> i' <br /> TYPE OF WORK (Check) : NEW WELL/_7 DEEPEN '/ / RECONDITION /_� DESTRUCTION /_ ; <br /> PUMP INSTALLATION '-F<7 PUMP REPAIR I / PUMP REPLACEMENT /_7 j <br /> Other / / — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY + <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 G� <br /> Domestic/private Drilled Dia. of Well Casing i <br /> Domestic/public Driven Gauge of Casingi <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary A 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 /> i <br /> PUMP .REPAIR: / / State Work Done <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 San Joaquin Local Health District <br /> and the State of California pertaining to or regulating we11 '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 A true to th best of my. k owledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR, IN AND A AL INSPE N. <br /> SIGNED TITLE <br /> RAW PL T PLAN 'ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATES/— # <br /> ADDITIONAL COMMENTS: ' <br /> PHASE II GROUT INSPECTION PHASE III/FINA16 INSPECTION i <br /> INSPECTION BY DATE INSPECTION' BY DATE <br /> 3175 2M <br /> E H 1426 Rev. 1-74 <br />