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n <br /> ---�� SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE 0�'FICE USE: 1601-E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> rte' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. }=� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7( <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. <br /> JOB ADDRESS/LOCATION77� --�Q Y �Q��- _ - CENSUS TRACT <br /> owner's Name e Phone <br /> el <br /> Address r i City <br /> Contractor's Name ��� �� ` � License # Phone <br /> TYPE OF WORK (Check) : NEW WELL /-7 DEEPEN / / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP. REPAIR / I PUMP REPLACEMENT <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 <br /> j 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 B -. <br /> PUMP INSTALLATION: Contractor to 'W / �� <br /> Type of Pump SPI H.P. <br /> PUMP REPLACEMENT: / State Work Done �`, f / /� - - <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 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 bes my..knowle and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR UTING AND A FINAL IN <br /> SIGNED 6 ITLE -7 177 Iz <br /> PLAN 'ON ERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT SPECTION PHAS I I/F NAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />