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y _ C SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F ...,.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,g-- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) O ( —c) " -37 <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 �.� �.•.Q CENSUS TRACT <br /> Owner's Name Phone Yo-3 <br /> Address <br /> y� City XG-4 <br /> Contractor's Name � ,� /f License Phone3c L a <br /> TYPE OF WORK (Check): NEW WELL/_7 DEEPEN /' RECONDITION IDESTRUCTION /_7 <br /> PUMP INSTALLATION g PUMP REPAIR -/-7—PW REPLACEMENT /_7 <br /> Other /_7 <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 OF WELL CONSTRUCTION SPECIFICATIONS <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 Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal OtherOther Information �.� �.,4. <br /> Geophysical <br /> Surface Seal Installed <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: / State Work Done <br /> PAIR: __./ / State Work Done --.�... <br /> i <br /> nES )NO_ F WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <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 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 A true to the-best-of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIO__ R TO GRO NG D A EjWjINSPEC1,10N. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I , <br /> APPLICATION ACCEPTED BY DAT `�� <br /> ADDITIONAh COMMENTS: I <br /> PHASE II GROUT IN PECTION PHASE III FINAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY DATE 1 <br /> E H 142.6 - Rev. 1-74 h/75 ?M <br />