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l��� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> I I APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7702 � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued,? <br /> (Complete In Triplicate) <br /> Application is Aereby 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 ""s, Rc let if ZFCENSUS TRACT <br /> Owner's Name <br /> •�Al Phone ,1 <br /> Address ZY. <br /> 31- d c*u <br /> ', City S7-ve1-"A..0 4 <br /> Contractor's Name �« � � License #.265761 Phone_?, Zy,6- <br /> _ _ a <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION f-1 DESTRUCTION /- <br /> PUMP INSTALLATION /X PUMP REPAIR / / PUMP REPLACEMENT /IZT-- <br /> Other / / T — <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 Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - � -- _ ._ _ H•P•• �i <br />.PUMP REPLACEMENT: State Work DoneCeA,,y <br /> PUMP •.REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 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 on a new well, I will furnish the San Joaquin Local. Health District a <br /> WELL DRILLERS REPORT of the welland 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 /> SIGNED ,1TITLE , . <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY 71 <br /> � .} <br /> APPLICATION ACCEPTED BY ,� DATE 3 /T 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GR T INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY AW DATE <br /> E H 1426 Rev. 1-74 , 1177 2M <br />