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SAN 30A4UIN WCAL ZEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. { <br /> FOR. <br /> FFiCE USE; Telephone: : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7_g y <br /> THIS PERMIT EXPIRES 1:°YEAR FROM DATE ISSUED Date Issued s=�1 V <br /> i <br /> t3,: (Complete In 'Triplicate) � <br /> Application 3s hereby made totheSate 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 /> r CENSUS TRACT <br /> JOB ADDRESS/LOCATI y <br /> r <br /> Phone 5 - 3,31 <br /> Owner's Name <br /> City CC <br /> Address. <br /> Phone <br />'�Cantraat01: e•-Name <br /> . ; DEEPEN <br /> .RECONDITION / DESTRUCTION <br /> TYPE OF WORK (Check). NEW WELL <br /> PUMP INSTALLATION / / PUMP REPAIR /_7� PUP'Q' REPLACEMENT /? <br /> Other <br /> f �3 <br /> DISTANCE TO NEAREST: SEPTIC TANK /SO' 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 /> Industria}. '� Cable Tool Dia. of Well Excavation / <br /> Domestic/private : t Drilled Dia.. of Well Casing " <br /> U Domestic/public i Driven Gauge of Casing <br /> _ Irrigation .,_L/ Gravel Pack Depth of Grout Seal. <br /> ' <br /> Cathodic Protection _._.✓_ Rotary Type of Grout <br /> Disposal OtherOther Information -- <br /> Geophysical Surface Seal. Installed B . NZ <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type` of Pump <br /> State Work Done <br /> PUMP REPLACENfENT: / / <br /> [—PUAH'�AIRS % State Work Done <br /> ES-TRUCTION OF WELT.; Well Diameter . <br /> 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 e b t>>of my knowledge and belief. I WILL CALL FOR A•GROUT INSPECTION <br /> PRIOR TO UTING AND WIFIX4 INSPECTVON. TITLE <br /> ` SIGNED f PLAN ON REVERSE SIDE <br /> FOR.DEPARTMENT USE ONLY <br /> PHASE I ' <br /> DATE <br /> APPLICATION ACCEPTED BY <br /> ! ADDITIONAL COHlENTS: ;4 _ P S I FI�11NSPEC ION <br /> P SE II ROUT INSPECTION _ INSPECTION BY ATE <br /> INSPECTION BY DATE ' <br /> 4 i-74 <br /> t E H 1426 Rev. 1.- 74 �.- <br />