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SAN JOAQUIN LOCAL HEALTH DISTRICT 10AI L <br /> FOE OFFICE U E: 1601 E. Hazelton Ave. , Stockton, Calif. 0y1��' <br /> 1117 Telephone : (209) 4666781 <br /> d <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 X774 <br /> 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 2J09CENSUS TRACT <br />-Owner's Name Phone --7(, /�-- <br /> Address _2423 �7 <br /> ue city <br /> Contractor's Name # <br /> ,s! p RA icense # Phone 'gf <br /> TYPE OF WORK'(Check) : NEW WELLDEEPEN/ / RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INST LATION /7/ PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LI ES 660 : PIT PRIVY <br /> SEWAGE DISPOSAUFIELD�I I� CESSPOOL/SEEPAGE PIT -OTHER <br /> P -1G-- <br /> ROPERTY LIN82 PRIVATE DOMESTIC.WELL4f2 PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS i <br /> Industrial Cable Tool Dia. of Well Excavation - �r f <br /> Domestic/private Drilled Dia. of Well Casing <br /> 042 <br /> Domestic/public Driven Gauge of Casing � E <br /> Irrigation Gravel Pack Depth of Grout Sea1 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Othe then Information <br /> Geophysical Surface Seal Installed B :4 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done j1 <br /> _ I <br /> i <br /> PUMP -.REPAIR: - / / State Work Done � -�-•- � <br /> i <br />©ES�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 <br /> .the State of California pertaining to or regulating well •con4truction. Within FIFTEEN DAYS <br /> aft, completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELD DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> inf-&rmation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />?RIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> W PLOT PLAN ON REVERSE SIDE) <br /> (3'R DEPARTMENT USE ONLY <br /> PHASE I �-�� --' <br /> APPLICATION ACCEPTED BY DATE <br /> AnDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P tE II /FIN�n INSPECT N <br /> INSPECTION BY DATE INSPECTION BY f/ DATE 1,7 <br /> c E 1426 RPV- 3-7L — r / [ ., Zek:Af/ 11. —� L �1 <br />