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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.Z --I <br /> THIS PERMIT EXPIRES l YEAR FROM-DATE ISSUED Date Issued9�/ <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 Jo4quin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> .TOB ADDRESS/LOCATION CENSUS TRACT <br /> -� W670 <br /> Owner's Name [ -- _ - - Phone ��=?;,X2 <br /> F Address 2s3ql �l City <br /> Contractor Name License # Phone <br /> 14) LY <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/ / RECONDITION /� DESTRUCTION /7 <br /> PUMP-INSTALLATION /"/ PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Otherl / / <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES . 15 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 /> I Industrial Cable Tool Dia, of Well Excavation '- (A <br /> Domestic/private _.._- Drilled. Dia. of Well Casing i <br /> Domestic/public ' Driven Gauge of Casing <br /> _ Irrigation ' Gravel Pack r� Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout' G <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B : <br /> i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> ( PUMP REPLACEMENT: / %Y ;State Work Done f{A <br /> PUMP .REPAIR: / / State Work Done <br /> t � _ - •• � T Y a�c <br /> DESTRUCTION OF WELL: Well Diameter . Approximate Depth <br /> Describe Material and Procedure <br /> U f <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 /> lafter 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 is true to the best of. my knowledge and belief-. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G OUTING AND A FIA&L INSPECTION. <br /> SIGNED TITLE <br /> f (DRAW PLOT PLAN ON REVERSE SIDE) ._ <br /> F <br /> FOR. -DEPARTMENT-,USE ONLY <br /> PHASE I ' <br /> APPLICATION ACCEPTED BY c DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPACTION PHASE III/FINAL INSPECTION <br /> INSPECTION 'BY DATE INSPECTION BY DATE <br /> 1 7 7 2M <br /> E H 1426 Rau- 1-74 -_ <br />