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oy <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT Q <br /> FOR..OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. /J <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL'CONSTRUCTION OR PUMP' PERMIT Permit No. 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1V <br /> (Complete In Triplicate) <br /> Application is Yiereby 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 $an Jaagu <br /> County Ordinance No.- 186a d the_Rules and Regulations of the San Joaquin Local Health District <br /> .TOB ADDRESS/LOCATION <br /> �� !�� <br /> ' CENSUS TRACT <br /> / <br /> Owner's Name' �� d`7L YPhone 14 <br /> Address � ��!'�"`-' _ <br /> City !` 'C I�Itt y <br /> Contractor's Name Licenses PhG 1 <br /> �r� ,..���-:-:.mss:..:... ._-.=t <br /> TYPE OF WORK (Check): NEW WELL i DEEPEN / / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION'/—/ pUMP-REPAIR /—/—PUMP REPLACEMENT ,f� <br /> Other` /. / ". <br /> DISTANCE TO NEAREST: SEPTIC-TANK r SEWER LINES . -SPIT PRIVY n' <br /> rSEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE• DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFI NS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> ,Domestic/private �' Drilled Dia. of Well Casing <br /> _` Domestic/public Driven.,. :. '. Gauge of Casing <br /> Irrigation <br /> Gravel Gravel Pack Depth of Grout.S <br /> Cathodic Protection ✓Rotary ' Type bf Grout / <br /> Disposal OtherOth' - c <br /> er Information ` <br /> Geophysical IN—Surface Seal:Installed By: <br /> PUMP INSTALLATION: _A'Contractor* <br /> Type of. Pump H.P. <br /> PUMP REPLACEMENT: f State Work Don <br /> PUMP .REPAIR.; / / State Work Done _r <br /> 3ESjRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> L hereby agree to comply with all laws and regulations of the San Joaquin Local, Health bi4trict <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 /> JELL 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 /> 'RIOR TO GROUTING AND A FINAL INSPECTION. <br /> iIGNEDL, ____/ TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> 'HAS E I <br /> 1PPLICATION ACCEPTED BY , �' DATE <br /> iDD ITI ONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION PHASE III/FINAL INSPEC ION <br /> :NSPECTION BY/,- , ;,r ., DATE INSPECTION BY DAT <br /> / <br /> F P IA94 n�__ i 7 ���� S'" ""J - 1 177 . rnt <br />