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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FbFRrOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7-S--S:5-)/0 ' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued j -/O,7,5� <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 / .,d.,,,XENSUS TRACT <br /> Owner's Name PhoneT 6 <br /> Address �f0 / City .� <br /> Contractor's Name _. License Phone I _ 3� <br /> TYPE OF WORK (Check): NEW WELL -17 DEEPEN 17 RECONDITION /7 DESTRUCTION /-7" <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /7 <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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing p\ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION; Contractor ., <br /> p <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: J / State Work Done <br /> PUMP 'REPAIR: /V State Work Done'/ d <br /> PES�T�RUCTION 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 GROMN24AND_A_U4kkT, INSPECTION. <br /> SIGNED TITLE <br /> kyDRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY AfDATE //h 7S <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FI AL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE 17 j <br /> ,j E H 1426 Rev. 1-74 <br /> 1-74 2M a <br />