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SAN JOAQUIN LOCAL HEALTH <br /> FOE OFFICE USE: V 1601 E. Hazelton Ave, DISTRICT 4C <br /> ? , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PENT Permit No. 7 -/ <br /> ffl <br /> VI <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ^� <br /> (Complete In Triplicate) bate Issued <br /> Application is hereby made to the San Joaquin Local Health District 'for a permit <br /> and/or install the work herein described, This application is made' in compliance w' <br /> Count Ordinance No, P to construct <br /> County 1862 and the Rules with San `Joaquin <br /> Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 1'0� <br /> Owner's Name CENSUS TRACT <br /> Address _�� <br /> Phone Ig <br /> Contractor's Name 00, <br /> City Zhxly�� <br /> License .11 � Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN <br /> / / RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP REPAIR /—/ PUMP REPLACEMENT /_7 <br /> Other /% � . <br /> DISTANCE TO NEAREST: SEPTIC TANK . <br /> SEWAGE DISPOSAL FIELDWER LINES PTT PRIVY <br /> PROPERTY LINE CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE _ PRIVATE DOMESTIC WELL <br /> TYPE OF WELL CONSTRUPUBLIC DOMESTIC WELL <br /> CTION SPECIFICATIONS <br /> Industrial �� Cable Tool <br /> Domestic/private Dia. of Well Excavation <br /> Domestic Drilled <br /> /public Driven Dia. of Well Casin ---� <br /> O <br /> Irrigation Gauge of Casing g '� �• <br /> Gravel. Pack Depth of Grout Seal <br /> Cathodic Protection y Type gyp` <br /> Disposal —� ype of Grout � p�� <br /> Geophysical Other Other Information <br /> Surface Seal Installed I3 ; <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> _ H.P, <br />'UMP REPLACEMENT: / / State Work Done <br />'UMP .REPAIR: State Work Done <br /> ESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> hereby agree to comply with all. laws and regulations of the San. Joaquin Local Health District <br /> nd the State of California pertaining to or regulating well construction, Within FIFTEEN DAYS <br /> fter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> ELL DRILLERS REPORT of the well and notif thein before putting the. well in use. The above <br /> nformation is true to the best of my k w edge, and belief. <br /> ZIOR TO GROUTING AND A L INSPECTIU I WILL GALL FOR A GROUT INSPECTION <br /> IGNED <br /> TITLE <br /> (DRAW PLO PLAN ON REVERSE SIDE <br /> 1ASE I FOR DEPARTMENT USE ONLY <br />'PLICATION ACCEPTED BY 7 �� <br />)DITIONAL COMMENTS: DATE <br /> fSPECTION BY <br /> PHAS II GROUT INSPECTION PHASE III/FI AL INSPECTION DATE -���,/--77 <br /> INSPECTION BY r DATE <br /> V <br />