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_,.mon,..... <br /> CSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 7LJTJt�/ <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 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/LOCATION 3 - CENSUS TRACT <br /> Owner's NameQ �/ Phone <br /> Address <br /> _ o w City 15'71 GC&Z:Ny <br /> Contractor's Name License # 7,1&2 Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /7/' DESTRUCTION /_7 <br /> AL <br /> PUMP INSTLATION REPAIR/ / 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 lu <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial — Cable Tool Dia. of Well Excavation <br /> X_ Domestic/private Drilled Dia. of Well Casing C11 I <br /> Domestic/public Driven Gauge of Casing <br /> 1 <br /> . <br /> g - <br /> Irrigation Gravel. Pack Depth of Grout Seal l <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information : <br /> Geophysical. Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 14-11 V-& [� <br /> Type of Pump f� H.P. ` <br /> PUMP REPLACEMENT: / / State Work Done <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 best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO-.6RCLUTING P A F NAL INSPECTION. <br /> SIGNED TITLE _ <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY - /Q DATE j <br /> ADDITIONAL COMMENTS: <br /> -- <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION - <br /> INSPECTION BY DATE INSPECTION BY e292 DATE <br /> E H 1426 Rev. 1-74 ` 1/77 2M <br />