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SAN JOAQUIN LOCAL. HEALTH DISTRICT "' "12/7/' <br /> LO r, OFFICE US Y�' 1601 E. Hazelton Ave. , .Stockton, Calif. ; <br /> ?` Telephone: (209) 466-6781 <br /> . APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7X <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date" Issued z;2,4�-?b� <br /> i� (Complete In Triplicate) ! <br /> Application i9 lereby made 'to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein' de scribed. 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/LOCATI N U r" CENSUS TRACTC � <br /> Owner's Name Phone --- <br /> Address City �S C'iC L•• a <br /> Contractor's Ncense IgZ j)3 Phone <br /> am <br /> TYPE OF WORK (Check) : NEW WELL /Pr-DEEPEN / / RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR '/ / PUMP REPLACEMENT - <br /> �; Other <br /> DISTANCE TO NEAREST: SEPTIC TANK�-SEWER -LINES!;�-� -PIT PRIVY <br /> SEWAGE DISPOSAL FIELD �ES SPOOL/SEEPAGE PI� OTHER -r <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USETYPE OF WELL CONSTRUCTION SPECIFICATIONS' <br /> I ustrial Cable Tool Dia. of Well Excavation /� `j <br /> Domestic/private Drilled A ' Dia.- of Well Casing <br /> ;rpomestic/public -Driven kms_-�,� --Gauge-of-,Casing- ;:� - <br /> Irrigation Gravel Pack. Depth of Grout S 1 <br /> Type <br /> Cathodic Protection ar Y YP of Grout ��•- - <br /> Disposal Other`, >Y Other Information R <br /> Geophysical '° Surface Sea1' Installed BY: �]! <br /> PUMP INSTALLATION: _ Contractor Lok e t <br /> =Type oPPump H.P. <br /> PUMP REPLACEMENT: / / State Work-Done <br /> PUMP .REPAIR: / / State Work Done. <br /> ^� 1. Approximate Depth �' - <br /> DESTRUCTION OF-WELL: Well Diameter i PP P <br /> t' 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 per 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 /> inform is true to the b owledge and belief. I WILL CALL FORA-GROUT INSPECTION <br /> PRIOR TO NG AND A FI I ON. <br /> SIGNED _ TITLE <br /> D LOT PLAN ON REVERSE SIDE) . <br /> i FOR DEPARTMENT USE ONLY #'A <br /> PHASE I <br /> APPLICATION jACCEPTED BY J,. - _ DATE ? Zg <br /> X. i y Y <br /> ADDITIONAL COMMENTS:' <br /> PHAS. g1h GROUT SPECTI N TM _ P S I/FTN INSPECTION <br /> INSPECTION BY ATE �� `� ;INSPECTION BY DATE <br /> E H 1426_ y Rev. 1--74 � — - <br />