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` ? SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> f FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. .�7.=� <br /> THS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made t I <br /> o 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 /> j JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name -p-pp. Phone .462-7216 <br /> Address -�nnn �, �1�er- _.. �..— City S109kton6t <br /> - Contractor's Name <br /> License # 2OO794Phone 948�:Z <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_/ RECONDIZ,.ION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPA PUMP REPLACEMENT /—T <br /> Other 1 <br /> DISTANCE TO NEAREST: SEPTIC 'TANK SEWER LINES PIT PRIVY <br /> SEWAGEIDIStOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHER \ j <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> IndustrialI Cable Tool Dia. of Well Excavation <br /> Domestic/private 1 Drilled rifled Dia. of Well Casing <br /> Domestic/public f Driven Gauge of Casing <br /> y, _ Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection A Rotary Type of Grout <br /> Disposal 1 Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION; Contractor Walt <br /> - - Type o�f Pump H.P. M 3 <br /> PUMP REPLACEMENT: / / State Work Done <br /> — S <br />._RUMP REPAIR. � Stat-e--Work-�.Done- <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply withlall 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 best of my- knowledge and belief. I' WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A 'FINAL- INSPECTION. ; <br /> SIGNED TITLE <br /> (DRAW P15T PLAN ON RE F-,P SE SIDE) <br /> "`r FOR DEPARTMENT USE ONLY <br /> PHASE I - <br /> APPLICATION ACCEPTED BY A DATE - `/ -177 <br /> ADDITIONAL COMMENTS: - "— <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 376 2M <br />