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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOSiOFFICE USE: / 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 1/ <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 741 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued7q- <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 4( CENSUS TRACT <br /> Owner's Name Phone o � <br /> Addresssp.2jg: City 5i2s, <br /> + License # r 3 Phone. � a <br /> Contractor's Name._ <br /> TYPE OF WORK (Check).- ' NEW'WELL DEEPEN/_� RECONDITION /? DESTRUCTION <br /> PUMP INSTALLATION / Y/ PUMP REPAIR /7 PUMP REPLACEMENT I"T <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 jOF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia.' of Well Excavation I <br /> V Domestic/private Drilled Dia. of Well Casing S f% <br /> Domestic/public Driven Gauge of Casing 0 <br /> Irrigation Gravel Pack Depth of Grout Seal 0 <br /> Cathodic Protection Rotary Type of Grouter e eri� <br /> Disposal # Other Other Information <br /> C-Geophysical -, Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H•P <br /> PUMP REPLACEMENT: State Work Done . <br /> PUMR !REPAIR_: L-7 State Work Done - <br /> ES.TRUCTION OF WELL: Well Diameter ' Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations ofthe San Joaquin Local Health District <br /> and the State 'of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after comp1 o f my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILL RS REP T of heri <br /> and notify them before putting. the..well in ,use.. The above <br /> informatillon ` tr e t of. my knowledge and belief. I WILL CALL FOR A'GROUT INSPECTION <br /> PRIOR TO GROU AND A SPECTION. <br /> SIGNED {! o��"""'�."..�.�-., TITLE W3'!.f � .tiG YY_t -•r <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY�o DATE ,.- �? <br /> ADDITIONAL COMMENTS: _ + "_ <br /> PHASE II GROUT INS <br /> PHASE III FINAL INSPECTION <br /> INSPECTION BX DATE 7,62 INSPECTION BY 2L DATE 1 5 <br /> Af <br /> it <br /> 1-74 2M <br /> E H 1426 Rev. 1-74 <br />