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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO&OFFICE USE; 1601 F. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELT, CONSTRUCTION OR PUMP pgRXIT Permit No. b- 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM .DATE .IS-SURD <br /> Date Issued <br /> OmPlete In Application is hereby made to the San `Joaquin Local Triplicate) <br /> Di-strict for a permit to construct <br /> 1 and/or install the work herein described. This application is made incompliance with San Joaqt <br /> County Ordinance No. 1862 and the Rules and Regulations of the San :Joaquin .Local Realth District <br /> i <br /> JOB ADDRESS/LOCATION �� o <br /> ' g , CENSUS TRACT <br /> -Owner's Name <br /> Phone <br /> i 'Address <br /> kJDa City. G <br /> i <br /> Contractor's Na <br /> I License # l l3-7)J—Phone cy�L--76 7< <br /> TYPE OF WORK (Check); NEW WELT, 'J7 DEEPEN -/ ~ RECONDITION /7 DESTRUCTION' PUMP INSTALLATION J PUMP REPAIR./ PuW REPLACEMENy- <br /> Other / / J-T <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES _ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD <br /> CESSPOOL/SEEPAGE "PIT <br /> PROPERTY LINE OTHER <br /> - PRIVATE DOMES <br /> SE PE OF WELL TIC WELL'— PUBLIC DOMESTIC WELL <br /> INTENDED UTY <br /> t _ Industrial CONSTRUCTION SPECIFICATIONS R <br /> Domestic Cable Tool Dia. of We11 Excavation <br /> /private , � Drilled <br /> Domestic/public , Dia, of Well .Casing S <br /> � Driven <br /> l C� Irrigation Gauge of Casing <br /> Cathodic Protection ""-- Gravel Pack Depth of Grout Seal <br /> Rotary Type of Grout <br /> Disposal ,Other. <br /> Geophysical --.�� Other Information <br /> Surface Seal Installd- B <br /> < <br /> PUMP INSTALLATION:<t 1 Contractor <br /> Type. -of Pump _ <br /> js-- <br /> PUMP / State Work Done- ��� <br /> PUMP .REP AIR: / / State Work Done , <br /> DESTRUCTION -OF WELL: Well Diameter <br /> Describe Material and Procedure APProximate Depth <br /> I hereby agree to comply with all laws and regulations of 'the San Joaquin "Local Health Distr <br /> rafter <br /> .and the,_State of California pertaining to or regulating well construttion. •Within FIFTEEN .DAYS ' <br /> completion of my work on a new well, I will furnish the San Joaquin "Local Health District a <br /> iWELL'DRILLERS REPORT of the well and notify them before -putting..the..well. in.use.. The above <br /> information is true to the best o£ m d belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A PINAL IN �GTIO Ile <br /> :SIGNED <br /> TITLE <br /> D W PLOT PLAN ON <br /> RSE SIDE <br /> WHASE I FOR DEPARTMENT USE ONLY <br /> `APPLICATION ACCEPTED BY <br /> ;ADDITIONAL COMMENTS: <br /> PHASE II GROUT INS CTION PHASE .III INAL 'INSPECTION <br /> INSPECTION HY DATE INSPECTION BY <br /> DATE _7 <br /> E H 1426 Rev. 1-74 <br />