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F0SAN JOAQUIN LOCAL HEALTH DISTRICT T <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: .. (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION -OR PUMP PERMIT Permit No. <br /> 7 -/S <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued 2,1_�k77/ <br /> Applica (Complete In Triplicate) <br /> tion is hereby made to the San Joaquin Local Health District for a permit to <br /> 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 �r <br /> X ENSUS TRACT <br /> Owner's Name <br />' <br /> Phone <br /> Address <br /> Name .�_ City <br /> Contractor's.-. ` - r <br /> m� � —1_ <br /> +L <br /> "-^ Pho4 <br /> -- - - - <br /> TYPE OF WORK (Check) : NEW WELL '/DEEPENi, <br /> RECONDITION E/ /fi DESTRUCTION /_7 <br /> � <br /> PUMP INSTALLATION /Z ; SUMP REPAIR' PUMP REPLACEMENT /- <br /> Other t { <br /> DISTANCE TO NEAREST: SEFTIC TANK <br /> - -,.'PIT PRIVY �"`��"— <br /> SEWAGE DISPOSAL .FIELD fnj, CESSPOOL'/'SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELT, ""xpUBLIC DOMESTIC WELL _� <br /> INTENDED USE TYPE OF WELL <br /> IndustrialLCONSTRUCTION SPECIFICATIONS <br /> mestic Cable Tool Dia, of We117Excavation A/ <br /> /private Drilled Dia, of Well Casing <br /> Domestic/public �� <br /> /public i Driven Cauge, of Casing <br />_irrigation ± Gravel Pack Depth of Grout Seal _ <br /> Cathodic Protectionqtr- otar /' ' <br /> y Type of Grout <br /> Disposal <br /> Geophysical Other Other Infozmati.on___ J <br /> ------ i <br /> _ Surface Seal Installed B <br /> PUMP INSTALLATION; Contractor ���� <br /> Type of Pump - <br /> _ <br /> H.P. <br /> PUMP REPLACEMENT: �--° �= -- - <br /> State Work Done <br />?UMP .REPAIR: Z/. State Work Done <br /> a <br />)ES•TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth ---- <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ind the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> ifter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> 1ELL DRILLERS REPORT of the well and notify them before putting the well in use.... The above <br /> nformation is true to the 'best of my knowledge and belief. I <br /> RIOR TO GROU INGD A FINAL INWILL CALL FOR A GROUT INSPECTION <br /> SPECTI <br /> IGNED <br /> TITLE <br /> (DRA PLOT PLAN ON REVERSE SIDE) "�--- <br /> HASE I FOR DEPARTMENT USE ONLY <br /> PFLICATION .ACCEPTED BY <br /> DDITIONAL COMMENTS: DATE <br /> 9SPEGTION BY (- <br /> PHASE II GROUT-DATE—INSPECTION, PHASE III/FINAL INSPECTION . <br /> '�T�- <br /> Z � '` INSPECTION BY DATE <br /> E H 1426 Rev. • ].-74 <br />