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( SAN JOAQUIN LOCAL HEALTH DISTRICT i <br /> -TO-F,-'OFFICE USE:, 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. L-5 1 g4: <br /> 77-sss Jd <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued. <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 /> Count y. Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB/ADDRESS/LOCATION C) ,' r <br /> t o CENSUS TRACT <br /> .k <br /> Owner's N alae �ss✓ Phone �� S <br /> Address <br /> {•-,ti�sz� City <br /> Contractor's Name 42-rc License #_Z 7 -Phone <br /> TYPE_OF. WORK .(Check) : :NEW WELL /7 -DEEPEN-/-7.._:_.RECONI]ITTON ./?_ DS.TRUCTION_%j _ <br /> PUMP INSTALLATION / � PUMP REPAIR L/ <br /> REPLACEMENT <br /> Other '17 � <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL-FIELD= - CESSPOOL/SEEPAGE PTT OTHER <br /> ' PROPERTY LINE - PRIVATE DOMESTIC WELD 'PUBLIC DOMESTIC WELL <br /> INTENDED .USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation Za <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public •�Dr-iven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sealer " Q� <br /> Cathodic Protection m _ Rotary Type of Grouter t <br /> Disposal Other -Other Information ' ' <br /> Geophysical Surface Seal. Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. + <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: • , <br /> State Work Done <br /> DS•TRUCTION OF WELL: Well DiameterApproximate-Depth . `3" - <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 are 'l,"I iaill"furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of t ' well and notify them before putting the well in use. The above <br /> information i rue to my k ledge and belief. I WILL CALL FOR A GROUT INSPECTION } <br />?RIOR TO GROU A FINAL NS CT <br /> SIGNED TITL <br /> DRAW LOT PLAN ON RE FRSE SIDE <br /> FO DEPARTMENT USE ONLY <br /> PHASE I ---- <br /> APPLICATION ACCEPTED BX DATE I y "77 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY /'/� DATE <br /> E H 1426 Rev. 1-74 , 3/76 2M <br />