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- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i F0R!OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone; . : (209)`466-6781 75 17S---1�' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit .No. ,7j-_ y,.6d <br /> THIS PERMIT EXPIRES l YEARFROM DATE ISSUED Date Issued //�,'- <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 thework 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 /> J <br /> JOB ADDRESS/LOCATION� <br /> CENSUS TRACT <br /> Owners Name Zt4 Phone <br /> Address ' City Lyc�G <br /> Contractor's Name C 1 icense X62373 <br /> Phone <br /> _ y Au �. -3 <br /> TYPE OF WORK .(Check):-- NEW WELL=/ DEEPEN-/ RECONDITION-17--DESTRUCTION <br /> PUMP INSTALLATION'/ PUNP'REPAIRY/_] Pump REPLACEMENT,�._�, <br /> _ .. Other/% - <br /> 1STANCE TO-NEAREST: SEPTIC TANK 0 SEWER LINES PITP <br /> Y, SEWAGE s - � SEWAGE DISPOSAL FIELD CE55POOL/.S�EPAGE 'PIT OTHER, <br />' ­PROPERTYLINE - PRIVATE DOMESTIC WELL P <br /> INTENDED USE TYPE O WELL UBLIC DOMESTIC WELT, <br /> j .. .,.- CONSTRUCTION SPECIFICATIONS �] <br /> l Industrial Cable Tool , Dia. of Well Excavation <br /> 'I}omes.tic/private Drilled x <br /> Dia. of Well Casing • . , <br /> Domestic/public Driven Gauge°_of Casing _ __ _ <br /> Irrigation .Gravel Pack Depth of.,Grout Seal <br /> Cathodic Protection dRotary - Type of Grotitr� <br /> Disposal YP 4•�•': <br /> ` Other Information ► .I <br /> Geophysical' Other. . ------ <br /> r Surface Seal Installed B � � <br />-.PUMP .INSTALLATION: <br /> Ccsntractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done .` <br /> F s <br /> PUMP`:REPA R:* n —/7`--Statel--Work•Done <br /> LS.TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth 8� <br /> I hereby agree to comply withal laws and regulatio;s of, he San Jaag11 Local Healt <br /> and the State of California pertaining to or regulating well construction. Within FIFTEENtrict DAYS <br /> after comp le n my work on new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILL S REPO T of the ell a notify them before Putting-the- well in-use. The above <br /> InformatiA is tru to t e. a t. y.knowledge and belief. <br /> PRIOR TO IN S CTIO <br /> I WILL CALL FOR A GROUT INSPECTION I <br /> R D <br /> SIGNED <br /> TITLE <br /> f . (DRAW PLOT PLAN ON REVERSE SIDE <br /> S _ <br /> PHASE I I FO DEPARTMENT USE.ONLY <br /> APPLICATION ACCEPTED iBY i <br /> ADDITIONAL COMMENTS.i DATE <br /> PHASE IZ GROUT I <br /> INSPECTION P <br /> RA <br /> INSPECTION BY - DATE INSPECTION B fF AI. DATEECTIO <br /> E H 1426 Rev. 1-74 <br />