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<7 r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0 !OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�02 Z g'� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> 4 (Complete In Triplicate) <br /> iy <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 aAd the Rules and Regulations of the San Joaquin Local Health District. <br /> `JOB ADDRESS/LOCATION Z21== CENSUS TRACT J 5 <br /> Owner's Name L)( Phone <br /> �/5 l�f.� C-�Yc� � !rte I'. <br /> r 'iAddress A City , <br /> (Contractor's Name /7 f R License # 4 Phone <br /> - . <br /> �*; "'� -� a.. fir" <br /> rtTYPE OF WORK (Check): WEL <br /> NEW L DEEPEN-'/-7 - RECONbTTIONI/� DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR ,/_7 PUMP REPLACEMENT f7 <br /> Other / / <br /> iDISTANCE TO NEAREST: SEPTIC TANK �0 ' 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 s, CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable,Tool% Dia. of Well Excavation <br /> �^ Domestic/private Drill d-,, < . Dia. of Well Casing f <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection _�7 Rotary Type of Grout <br /> _Disposal Other Other Information <br /> Geophysical f ' Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type' of Pump H.P. <br /> PUMP REPLACEMENT: / / , State Work Done <br /> i <br /> i PUMP .REPAIR: /? State Work .Done.. <br /> • ....�., Approximate th- <br /> A n_� �. ;� De <br /> ,RES•TRUCTION OF WELL: " <br /> Well_Diameter_" "�"`�' pp p <br /> - Describe Material and Procedure <br /> .I 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 GROUTING D A FINAL NSPECTION. <br /> SIGNED TITLE <br /> (WE PLOT PLAN ONi*RSE SIDE <br /> --FOR DEPARTMENT USE ONLY <br /> . I PHASE I <br /> APPLICATION ACCEPTED BY - DATE <br /> I ADDITIONAL COMMENTS: Z / <br /> PHASE 1GROUT INSPECT12N I NAL INSPECTION <br /> INSPECTION BY DATE INSPECTIO DATE -7-7 <br /> �� E H 1426 . Rev. 1-74 1-74 2M <br />