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SAN JOAQUIN FOCAL HEALTH DISTRICT <br /> FO&.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> ' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued 7 A-17 <br /> (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 Joaquil <br /> County Ordinance No. 1862 aid the Rules and Regulations of the San Joaquin Local Health District. <br /> k <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> r R Phone 1 <br /> Owner's Name J , �� � f,1� 9 ;Nlllf� <br /> Address 'Sig, _-z City <br /> 14.40 .i <br /> Contractor"s't Name , License �� 7 � Phone <br /> TYPE^OF WORK (Check) ! NEW WELL/ / DEEPEN / / 'RECONDITION / / DESTRUCTION /_7. PUMP. INSTALLATION `I I PUMP REPAIR/ / PUMP REPLACEMENT / <br /> Other /_7 , <br /> DISTANCE TOyNEAREST: e SEPTIC TANK SEWER LINES'. PIT PRIVY <br /> (' SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROP ERTY_;IN'E—=.PRIVATE DOMESTIC�WELL' PUBLIC DOMESTIC WELL C <br /> INTENDED USE TYPE'-OF,WELL ` CONSTRUCTION SPECIFICATIONS <br /> Industrial ; •,__Cable Tool Dia: of Well Excavation <br /> Domestic/private "<', _ Drilled Dia. of Well Casing _ <br /> Domestic/public Driven Gauge of Casing r <br /> Irrigation i t-G-r•avel Pack Depth of Grout Seal t <br /> Cathodic Protection Rotary Type of Grout i <br /> Disposal - , ___Other Other Information <br /> Geophysical �""` "-`—,surT ccs aal in--tail <br /> PUMP INSTALLATION: s Contractor <br /> Type of Pump } H.P. <br /> W' f <br /> PUMP REPLACEMENT: /, S tateWork <br /> PUMP .REPAIR: /_/ S;tat&, WW D.on'e <br /> DESTRUCTION OF WEDI;:: Well Diameter "f ' Vol `�` Approxiivate`'Depth i <br /> Describe Material an&Procedure E <br /> I hereby agree toycomply with all laws and regulations of the San Joaquin Local-Health District <br /> and the State of California pertaining to or regulating well'-construction. ' Wi,tihin FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin L'ocal'Health District I <br /> rWELL DRILLERS REPORT of the well and notify them before putting the -well in, use:. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL F AIGROUT INSPECTION <br /> PRIOR TO GROUT NG ANDA I AL INSPECTION. <br /> . SIGNED <br /> + TITLE ' �" d3 <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> I PHASE I <br /> APPLICATION ACCEPTED BY I DATE J Z <br /> ADDITIONAL COMMENTS: i 1 <br /> PHASE II GROUT INSPECTION PHAS II7JFINAL INSPEC ION ' <br /> INSPECTION BY x DATE INSPECTION BY FCtA DATE :) <br /> E H 1426 Rev. 1-74 1177 2M__ <br />