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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR, OFFICE USE: l 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 71 as P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) :�2L tef,Y/ro,.-4(-- <br /> Application <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 Joa4,uin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ISUS TRACT <br /> Owner's Name �, ��"""T Phone fJ�✓J ~ � _� <br /> Address �� City k�5C� �� <br /> Contractor's Name �� � � License # WPhone d. <br /> TYPE OF WORK (Check) : NEW WELL/ J DEEPEN/ / RECONDITION /—/ DESTRUCTION /_7 <br /> PUMP INSTALLATION J / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> pA <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 Ph . <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <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 H.P. <br /> PUMP REPLACEMENT: / State Work Done , za� astqlz <br /> t <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 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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRQTTtNG AND A FI AL INS ECTION. <br /> SIGNED1 TITLE e <br /> (DRAW PLOT PLAN ON REVERSE SIDE) Y <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ? DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE I�,G OUT INSPECTION PRASE IIIJ , INAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BYDATE „ <br /> E H 1426 Rev. 1-74 1177 2M <br />