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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS OFFICE DISE: 1601 E. Hazelton Ave. , .Stockton, Calif. � <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-1396 <br /> THIS ,PERMIT EXPIRES 1. YEAR FROM .DATE ISSUED Date Issued <br /> F <br /> (Complete In Triplicate) <br /> k Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the works herein described. This application, is made in compliance with San Joaquin <br /> G County Ordinance 'No. 1862 and the Rules and Regulations of the San-Joaquin Local Health District„. <br /> t JOB ADDRESS/LOCATION R re N e CENSUS TRACT <br /> f — <br /> Owner's Name. Phone <br /> Cit <br /> Address ,o �+•C �y,�. y <br /> Contractor's .Name. is .License_��-�6_� __F.hone- <br /> . f1. <br /> TYPE OF WORK (Check) : NEW WELL / I DEEPEN/ I RECONDITION /_/ DESTRUCTION /� .� <br /> :PUMP INSTALLATION / / PUMP REPAIR /44 PUMP REPLACEMENT /-7 <br /> Other <br /> 4 <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 <br /> INTENDED USE TYPE OF WELL I i CONSTRUCTION SPECIFICATIONS - <br /> ! Industrial Cable Tool �' ;,Di-a: 'of"Well-'Excavation <br /> Domestic/private: Drilled ; Dia. of Well Casing <br /> Domestic/public Driven Gauge_ of Casing 0 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type. of Grout <br /> Dispo-sal Other '_ Othe'r' -Information <br /> Geophysical ! Surface Seal Installed By: <br /> F <br /> PUMP INSTALLATION: ��Contractor <br /> \' Type of Pump H.P. ' <br /> PUMP REPLACEMENT: I State Work Done <br /> PUMP .REPAIR:'' li lAi' State Work Done 67eAdcc! -- <br /> I DES-TRUCTION OF WELL: Il Well Diameter Approximate Depth <br /> t iDescribe Material and Procedure` <br /> l hereby agree to comp;ly with all laws and regulations of the San Joaquin Local Health Distract <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion' of mywork 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 t:rue .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 OL TITLE -a4 ,. <br /> t it (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I +_ ii <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS !I <br /> S PHASE II ',GROUT INSPECTION PHASE III/FINAL INSPECT ON <br /> INSPECTION BY r 0 DATE INSPECTION BY DATE <br /> ii/7�_�214 <br /> E H 1426 Rev. - I-74 <br />