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G SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> FOR(.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit: No. t/- 71 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> `14 ct (Complete In Triplicate) 06l - G`/-,0 --37 <br /> Application is hereby made to the San Joaquin Local Health District fora 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 .(A �G b�.� C 1 <br /> CENSUS TRACT <br /> Owner's Name Phone-3 L - <br /> Address , t cC.2 City a <br /> Contractor's Name License I// ] Phone <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN '/_ RECONDITION /-7 DESTRUCTION /-7 <br /> ./ <br /> PUMP INSTALLATION / PUMP REPAIR PUMP REPLACEMENT /7 <br /> Other /7 i <br /> f <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 I YPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled r Dia, of Well Casing <br /> Doinestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack' Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout `. <br /> Disposal : Other ! Other Information _ <br /> Surface Seal. Installed-By:. ...�.. <br /> PUMP- INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done _ <br /> PUMP ,REPAIR: State Work Done <br /> ---- _,.. <br /> ES-TRUCTION OF WELL: Well Diameter `' Approximate Depth <br /> Describe Material and Procedure <br /> s <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 ip. true to the-best-of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO N D INSPECTION. <br /> SIGNED _ TITLE c <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> 77 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II T INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE `' - INSPECTION BY DATE - <br /> _.. , <br /> E H 1426 Rev. 1-74 1-74 2M <br />