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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> —FO--F,--'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _11 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued a-- p-27 <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 gulations of the San jJoaquin Local Health District. <br /> JOB ADDRESS/LOCATION Sklee4 +- CENSUS TRACT <br /> Owners Name Phone ��3 7/ <br /> ee c <br /> Address City <br /> Contractor's Name c; License 1/6 lyn Phone • 73 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /—/ DESTRUCTION /-7 <br /> PUMP INSTALLATION/ / PUMP REPAIR 0 PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 /> 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 /> �� '~ <br /> Type of Pump `�' H.P. a -- <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: JSC/� 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 rue to the st of y knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR G D INSPE ION. <br /> SIGNED TITLE _ /:_ <br /> DRAW Pi, T PLAN ON REVERSE SIDE) 1 �'7 1% <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I l <br /> APPLICATION ACCEPTED BY DATE Z / <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />