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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77- <br /> THIS <br /> 7-THIS PERMIT EXPIRES 1 YEAR FROM 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 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 jp CENSUS TRACT <br /> Owner's Name Phone d— !`/L <br /> Address 5 City LSCIAL9112 <br /> Contractor's Name .�� , ,: p ,l 4 S 6 n7 License #,2220,jD Phone W .2o7 <br /> —..ter---V•r��..•..,.r.r�.r ____—__ ....T.+r..��n•.r�rr �—_ .�..•.r....r...n+-rr.r+.w <br /> TYPE OF WORK (Check) : NEW WELL / / -.DEEPEN / / RECONDITION / / DESTRUCTION /_7 <br /> PUMP-IDISTALLATIOIV `/ `/ ,PUMP REPAIR "/ / PUMP REPLACEMENT <br /> =OtY e- % �- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD - CESSPOOL/SEEPAGE PIT OTHER \ <br /> PROPERTY LINE - PRIVATE TOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia:.—of-`Wee11"Excavation <br /> Domestic/private Drilled Dia. of Wel1.,Casing <br /> Domestic/public Driven Gauge of Casing l" <br /> s <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Pr__otection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical- Surface Seal'.Installed B : <br /> PUMP INSTALLATION: Contractor <br /> ---Type- -Pum--F­ � _ V �__---�--w- H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP ,.REPAIR: / / State Work Done <br /> DESTRUCTION 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 'constr'uction. 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 knowledge and belief.._J_WDLL_CALL F R 'A GROUT INSPECTION <br /> PRIOR TO GROU ING AND A F NAL INSPECTION. <br /> SIGNED TITLE' �l•.�i► <br /> {DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY f <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE ITGROUT INSPECTION INSPECTION G- PRAS- IIIki`INAL INSPECTION . <br /> INSPECTION BY DATE <br /> INSPECTION BY'�.► DATE .t <br /> 1777 2M <br /> E H 1426 Rev. 1-74 <br />