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SAN JOAQUIN LOCAL ; <br /> fiEALTH DISTRICT <br /> F0� OFFICE USE: 1601 E. Hazelton .Ave. , Stockton, Calif. <br /> Telephone : . (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES Z 'YEAR FROM DATE ISSUED 1AN <br /> 3'- <br /> , .Date Issue � <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin- Local Health-District for .a..p <br /> and/or install the work herein described. strct <br /> This application is made in. complianceermit 'twith nSanuJoa u <br /> County Ordinance No. .1862 and the Rules and Regulations of the :San Joa uin L 4 <br /> q ocal Health. District <br /> JOB ADDRESS/LOCATION �Ij <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address B /�j� <br /> .1 City <br /> Contractor's Nam <br /> License # hone _ _7k7 <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN <br /> _/ / RECONDITION /_/ DESTRUCTION /? <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other / / 4 <br /> A � <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - <br /> SEWAGE DISPOSAL FIELD PIT PRIVY <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL A <br /> INTENDED USE TYPE OF WELL <br /> Industrial } CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia, of Well Excavation <br /> Domestic/private { Drilled Dia, of Well Casiing <br /> IrrigaDomesttion <br /> 1 Driven Gauge of Casing T � <br /> Irrigation ! Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 1 Rotary Type of Grout <br /> Disposal yp <br /> 1 _ Other Other Information <br /> Geophysical f Surface Seal Installed B : <br /> PUMP INSTALLATIONc Contractor <br /> TYPe`of 'Pump -7— <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: Y�X/ State Work Done f <br /> # 7 <br /> DES-TRUCTION OF WELL: Well Diameter <br /> :""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. onja 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 knowledge—anal belief. <br />'RIOR TO GROTINI WILL CALL FOR A GROUT INSPECTION <br /> G AND A FINAL NSP CT N <br /> ITLEi^ ,. . <br /> (D W PLO PLAN ON SSE SIDE) <br />'RASE I FOR DEPARTMENT USE ONLY <br /> 1PPLICATION ACCEPTED B <br /> kDDITIONAL COMMENTS: DATE <br /> PHASE IT GROUT INSPECTION P E I/ INAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE 8 <br /> E H-,:�1,426 Rev <br /> �1-74� <br />