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w <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOkOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 P <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _�ni_97 w <br /> 'THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) ' <br /> Application is hereby made tolthe San Joaquin-Local Health District for a permit to construt <br /> and/or install the work herein described. This application is made in compliance with San J aquin <br /> County Ordinance No 8 2 and!the Rules and Regulations of th San Joaquin Local Health Dist ct. <br /> JOB An s/I.00ATI r y -5" A-7e9 CENSUS TRACT <br /> Owners Name -- - �- o f )t/f /-j 01 / Phone <br /> Address ] �i�G�1f �� �. City <br /> Contractor's Name 7w / License /�i��� Phone�0-'�'4f_r I <br /> . t r <br /> TYPE OF WORK (Check)- ., NEW WELL DEEPEN -/ RECONDITION / DESTRUCTION /_7' PUMP INSTALLATION L�f PUMP REPAIR ,/7- -pump REPLACEMENT /- <br /> Al <br /> /Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER_ LINES4 ! PIT ,PRIVY <br /> 0—,v SEWAGE DISPOSAL FIELD rvJCESSPOOL/.SEEPAGE PIT . , OTHER 'S j <br /> /- PROPERTY LINE - PRIVATE DOMESTIC WELL, PUBLIC DOMESTIC WELL <br /> MEW-- - <br /> INTENDED USE TYPE OF WELL f ;,-,�­�•;,�r.CONSTRUCTION SPECIFIC I S ' <br /> Industrial Cable-Tool -Dia:of Well Excavation <br /> Domestic/private F Drilled Dia. of Well Casing' -' <br /> Domestic/public Driven Gauge of Casing .� <br /> Irrigation i Gravel Pack Depth of Grout Seal i -- <br /> Cathodic Protection ; Rotary Type of Grout . <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: - y <br /> PUMP INSTALLATION: Contractor 7 � y �S <br /> Type of Pump / �774 �TU3 / H.P. ,jam <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP-i REPAIR:— 'State Work—Done - <br /> ,RES TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> � E <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 is true to the-beat of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED ^ -77 7Z,7 _ TITLE <br /> _ <br /> (DRAW PLOT PLAN ON REVERSE SID _ <br /> ^ FOR DEPARTMENT USE ONLY T <br /> PHASE 1' <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT .INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION 'BY DATE INSPECTION BY c + DATE <br /> 61 <br /> t E H 1426 Rev. 1-74 1-74 2M ' <br />