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K SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �Ucc <br /> THISIPERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application isiIhereby made tolthe 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/LOCATIONa % :; ,.BQ�T'c�nk, l- - _ . /] L '-�__ CENSUS TRACT <br /> Owner's Name Phone <br /> Address 3 3 SV ` i -� l City Contractor's Name License #/6 )-373 Phone3 -3 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/ / RECONDITION /_7 DESTRUCTION /_7 „ <br /> PUMP INSTALLATION / / PUMP REPAIR �' PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: : SEPTIC TANK SEWER LINES PIT PRIVY <br /> ; SEWAGE DISPOSAL FIELD i CESSPOOL/SEEPAGE PIT OTHER • <br /> PROPERTY,LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL W <br /> INTENDED USE j TYPE OF WELL CONSTRUCTION SPECIFICATIONS �• <br /> Industrial [. 41 Cable Tool Dia. of We11 Excavation l <br /> Domestic/privati� Drilled Dia. of Well Casing Cl <br /> Domestic/publid', 11 ,- Driven Gauge of Casing <br /> "I r W Pack � Depth of Grout Seal <br /> Irrigation i �, Gravel p <br /> Cathodic, P.ro tec'tion 1 i� Rotary Type of Grout <br /> Disposal; 'f. f ; Other Other Information ' <br /> r <br /> Geaphysica ;/ Surface Seal Installed By:- <br /> ,. , <br /> PUMP INSTALLATION: Contrac %ar <br /> _ Type_of Pte_ E H.P.Q <br /> PUMP REPLACEMENT: / / State Work Done' f, <br /> PUMP .REPAIR: /�_TrState Work Done ' <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> V, <br /> I hereby agree to comply with all laws and regul*ions of the San Joaquin Local Health District <br /> and the State of California pertaining to or regu'j.'ating 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 ue to the best of. my knowledge zk`nd-'belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT AN A FINAL' SPECTIO <br /> SIGNEDTITLE <br /> DRAW PL T PIsAN 'ON REVERSE SIDE ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY i DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE /d <br /> 3/76 2M <br />,I E H 1426 Rev. 1-74 <br />