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SAN JOAWIN=LQCAL'I ALTH DISTRICT <br /> ` OR+(OFFICE USE: 1601 E. Hazelton''Ave."; e5tockton, Calif. <br /> s <br /> Telephone: r (249) 466-6781 <br /> APX'LTCATTON FOR WELL GONSTRUCTION OR PUMP •PERMIT Permit No. - .. L <br /> jr <br /> THIS PERMIT EXPIRES 1..YEAR47ROM DATE+ISSUED Date Issued 2- <br /> - (Complete In 'Tri <br /> -- (Com lete_ In 'Tri licate) <br /> Application is hereby made' to the San Joaquin.local -Fiealth• Distriet' 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.t 1862, and the Rulesand <br /> _Regulations(. -of the :San Joaquin Local Health -District. <br /> JOB ADDRESS/LOCATION <br /> -� #15P2CENSUS TRACT <br /> Owner s: Name Phone <br /> .Address. . City <br /> Contractor's Name Ca License Phone//133 OW- <br /> TYPE <br /> TYPE OF WORK (Check) : NEW WELL -/_7 DEEPEN -1K RECONDITION / DESTRUCTION f7 <br /> PUMP .INSTALLATION� / / PUMP REPAIR / / PUMP REPLACEMENT r <br /> Others <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 WELL <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 1 Driven Gauge of-Casing <br /> Irrigation °i Gravel Pack Depth of Grout Seal, \ <br /> Cathodic Protection r- :`'Rotary Type of"Grout <br /> Disposal f Other Other Information ', <br /> Geophysical Surface Seal Installed Ay! ZF <br /> PUMP INSTALLATION. <br /> Contractor .. <br /> Type 'of Pump WH.P. <br /> -�: <br /> l PUMP REPLACEMENT: / / State Work,Done <br /> I <br /> PUMP�'.REPAIR: /7 State Work Done <br /> ,SES-TRUCTION OF WELL: Well ;Diameter Approximate Depth <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 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.best of my_knowledge­and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTWG AND A FINAL I PECTION. <br /> SIGNED I TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE - � -J 6. <br /> ADDITIONAL COMMENTS:��5 rte• <br /> PHASE II 5ROUT INSPEC ON PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE 'INSPECTION BY DATE 7 <br /> E H 1426 Rev. 1-74 1-74 2M �` <br />