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SAN JOAQUIN LOCAL HELTH.DISTRICT <br /> FOR'OFFICE USE• 1601 E. Hazelton Aqe -'; tockton, Calif. ' <br /> Telephone: (209) 466=6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�% 74� <br /> THIS PERMIT, EXPIRES 1 YEAR- FROM DATE ISSUED Date .Issued 1 I <br /> (Complete in Triplicate) 2-0 3 6-5o r3o <br /> r` ct <br /> Application is hereby made to <br /> the San <br /> usieoapplicati n isth �made inrict rcomplancetwith San uJcaquin <br /> and/or install .the work herein described. <br /> , s and Regulations of the San Joaquin Local Health District. <br /> Cou�aty Ordinance No. 1862 and theRule <br /> 5- j—A,CZC- 7'"V� � * CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> v Phone r 3 Z-- <br /> Owner°s Name _ <br /> City <br /> Address <br /> -,t,-- <br /> Address Cit Phone <br /> License # -� - <br /> Contractor's Name a i <br /> PDESTRUCTTYPE OF WORK (Check): , NEW WELL /7 P / PUMP RECONDITION <br /> UMP REPLACIEMENT <br /> PUMP INSTALLATIONI -- I <br /> Other <br /> ' _ PIT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINECESSPOOL/SEEPAGE PIT OTHER <br /> SEWAGE�DISPOSAL FIELD ----- <br /> ._ PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> ONSTRUCTION SPECIFICATIONS <br /> INTENDED USE <br /> Industrial �, Cable Tool <br /> Dia: of-Wel1"Excavation <br /> ---~ Drilled `.Dia.;,-Of-.' <br /> Casing <br /> Domestic/private �~ t . <br /> 3J ? t Driven Gauge of Casing <br /> Domestic/pubs c.; {,- ; Gravel Pack -x Depth of Grout Seal <br /> Irrigation <br /> �— Rotary � .� �'`� TYPe of Grout <br /> Cathodic Protection i �— Other ' �tih'er Information <br /> i Disposal �— Surface "Seal Install d B i <br /> Geophysical <br /> PUMP INSTALLATION; Contractor H.P. <br /> Type of Pump - --~- <br /> 1 State YWork Done <br /> PUMP REPLACEMENT. 11, <br /> PUMP '.REPAIR S - State�Wor'I- - <br /> Approximate_Depth <br /> ESjRUCTION OF WELL: -= Ws]+1>Diameter <br /> Describe Material and Procedure <br /> I hereby agree to comply with- all laws7and regulations of_ t-he San Joaquin Local Health District <br /> and, the State of California pertaining to-or regulat.liiCwell construction. Within FIFTEEN DAYS <br /> ' after completion of my work on a new-,4ell,-=l-will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of the.-wdfi�ai dij#o— ify them before putting. th <br /> e .well in.use.. The above <br /> ,- ,- _ ; <br /> information is true-to the-bent of my knowledge and belief. I WILL CALL FOR A GROUT INSPECT <br /> ION <br /> } PRIOR TO GROUT'NAND A`"FINAL INSPECTION. TITLE <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE; SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I a DATE <br /> f T PLICATION ACCEPTED B - � <br /> AP � y <br /> ADDITIONAL COMMENTS: P IN INSPECTION <br /> PHASE II GROUT INSPECTION , INSPECTION B AT <br /> -INSPECTION BY DATE <br /> =r '� 1-74 2M <br /> E H 1426 Rev. 1-74 <br />