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vrf _ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB OFFICE USE: 1601 E. Hazelton Ave.. , Stockton, Calif. <br /> a <br /> Telephone: (209) 466-6781` <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7ti_/Lo33/o <br /> THIS PERMIT EXPIRES 1 YEAR ;FROM DATE ISSUEDDate Issued <br /> .� (Complete In Triplicate) <br /> Application- is Hereby made to the San Joaquin Local healthDistrict fof 'a -permit .to .c6h truct <br /> and/or install the work herein described. This, appi.ication is made 3n, compliance with San Joaquin, <br /> ;County. Ordinance No. 1862 and the Rules and Regulations of the San -Joegdfu'Local .Health District. <br /> ,JOB ADDRESS/LOCATION � A132 CENSUS TRACTS <br /> Owner's Name Phone <br /> '.Address �-� City <br /> 'Contractor's Name License / 6.-5 Phone ��r <br /> �TYPE .OF WORK (Check): NEW WELL ,f T DEEPEN '/-T- RECONDITION f-7 DESTRUCTION <br /> PUMP INSTALLATION UMP REPAIR-/ : Pump REPLACEMENT <br /> Other %{ <br />, .,DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES . PIT PRIVY { <br /> SEWAGE_DISPOSE-FIELD _� CESSPOOL/SEEPAGE PIT -OTHER <br /> PROPERTY LINE - PRIVATE DOIIESTIC -WELL' PUBLIC.-DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS f <br /> Industrial Cable Tool Dia. of Well Excavation W <br /> k Domestic/private Drilled Dia. of Well' Casing .. ' <br /> Domestic/public Driven Gauge of .Casing <br /> Irrigation Gravel Pack- Depth of Grout Seal " (A <br /> - Cathodic'Protection Rotary Type of Grout "l <br /> Disposal Other Other Information <br /> Geophysical Surfaw Seal Installed 'B <br /> PUMP INSTALLATION: Contractor <br /> ' Type .of Pump H.P. <br /> IPUNP REPLACEMENT: . / / State Work Donee <br /> PUMPIREPAIR: / { State Work Done - - _ <br /> ' DESTRUCTION OF WELL: Well .Diameter Approximate Depth <br /> Describe Material and Procedure <br /> k <br /> II, hereby agree to comply with all laws and reguiations .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 DR REPORT of the well and notify them before putting..the..well. in.use... The above <br /> info ation true to t • est-ofXON.knowledge <br /> and belief. I WILL 'FOR 'A GROUT INSPECTION <br /> F!RIOR GROU G 'AND A I SP <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON 'REVERSE SID <br /> FOR DEPARTMENT USE ONLY " <br /> .PHASE I , <br /> APPLICATION ACCEPTED BY DATE /a <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY. OV DATE/6, l <br /> w YES 1426 Rev. 1-74 - tt 75 2M <br />