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. SAN JOAQUIN LOCAL HEALTH DISTRICT � <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , -Stockton, Calif. <br />' <br /> Telephone : (209) 466--6781 y� <br /> f APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No✓/�. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .9—1Q-77-- <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION , -- CENSUS TRACT <br /> Owner's Name Q Phone t, <br /> t <br /> Address 0 <br /> I T City <br /> Q A <br /> Contractor's Name -� j / License # 3'k hone <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN / / RECONDITION /_/ DESTRUCTION /_ _ <br /> PUMP INSTAL ATION / / PUMP REPAIR / / PUMP REPLACEMENT— <br /> Other <br /> EPLACEMENTOther / J <br /> DISTANCE TO NEAREST: SEPTIC 'TANK SEWER LINES PIT PRIVY <br /> � ^^� SEWAGE DISPOSAL FIELD KZM _ CESSPOOL/SEEPAGE PTT _, OTHER <br /> cc PROPERTY <br /> LINE :Q PRIVATE DOMESTICX <br /> WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL - <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial <br /> Cable Tool Dia, of Well Excavation s i <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of 'Casing / . } , ! <br /> Irrigation Gravel Pack �+ Depth of Grout. Seal "i <br /> Cathodic Protection Rotary Type. of Grout <br /> Disposal Other Other Information <br />` Geophysical Surface Seal Installed By: �{ <br /> PUMP INSTALLATION: Contractor ; <br /> type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: J J State Work Done <br /> i <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure ' <br /> i <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertainiing to or regulating well. 'construction. Within FIFTEEN DAYS <br /> after completion of mywork 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 puttingthewell in use. . The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION I�I <br /> PRIOR TO GRO I G D IN INS TION, i <br /> SIGNED TITLE e <br /> .1 (DRAW PLOT PLAN ON REVERSE SIDE) _ <br /> FO DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ` ,�� DATE `7 <br /> 11 tX7 <br /> ADDITIONAL COMMENTS: "" <br /> PHASE GYPLIT INSPECTION P E III/F NAL INSPECTION j <br /> INSPECTION BY - DATE �7 INSPECTION BY DATE - a� <br /> E H 1426.._. Rev. . 1-74. s. �.. 6>r77 _ 2M ._.. . <br />