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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. , 1 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued- <br /> _Y4- <br /> j (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 Joaquin <br /> County Ordinance No. 1862 and' the Rules and Re tions of the San Joaquin Local Health District: <br /> JOB ADDRESS/LOCATION ® CENSUS TRACT <br /> Owner's Name Phone <br /> t <br /> Address City r <br /> Contractor's Named �-� License Phone" , <br /> TYPE OF WORK (Check) : NEW WELL L. DEEPEN ./ RECONDITION DESTRUCTION L7 <br /> PUMP INSTALLATION k-'I- PUMP REPAIR /? PUMP REPLACEMKNT /-'7 <br /> Other <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 ULL ' <br /> INTENDED USE i TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> IndustrialCable Tool Dia. of Well- Excavation <br /> Domestic/private Drilled Dia. of Well Casing :. Q <br /> Domestic/public Driven Gauge of Casing \ j <br /> Irrigation ; g Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B : ' <br /> PUMP INSTALLATION: Contractor j� � AZ5 <br /> Type of Pump H.P. " <br /> j p <br /> PUMP REPLACEMENT; / / .,,State Work Done <br /> PUMP .REPAIR: / / + State Work Done <br /> DESTRUCTION 'OF WELL: Well Diameter Approximate Depth °. : r <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 .FIFTBNt IS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a j <br /> WELL" DRILLERS. REPORT of ►the well and notify them before putting` the .we in use. The above <br /> information is .true to the best of my-knowledge and,bel:ef. I WILL FOR A GROUT T$SPECT1W. <br /> PRIOR TO G UTING 'FINAL INSPECTION. ,. 1 <br /> SIGNED _ "" "' y TITL l <br /> ;..-� <br /> '1-(DRAW-.:�WT PLAN ON REVERSE SIDE ,... , <br /> "° i R ART USE ONLY <br /> PHASE I <br /> APPLICATION-ACCEPTED BY;'---` DATE <br /> ADDITIONAL iAMHENTS: <br /> PHA E I GROUT INSPECTION PHAS r INSPRC <br /> INSPECTION BYOr DATE INSPECTION BY DA'Z'E <br /> '. <br /> r E H 1426 Rev. 1.-74 ' � 3176 2�4 <br />