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E SAN JOAQUIN LOCAL <br /> FOR, HEALTH�DISTRICT <br /> FOR, OFFICE USE; y 1,301 E. Hazelton Ave. ,' Stockton, Calif. ' <br /> Telephone : (209) 466-6781 <br /> ' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �q � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issue�cI ��� r <br /> Applica (Complete In Triplicate) <br /> tion 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 withlSan Joaquin <br /> County Ordinance No. 186_ and!the Rules and Regulations of the San Joaquin Local HeAlth" District. <br /> JOB ADDRESS/LOCATION %�y� � /� <br /> 11 <br /> y <br /> CENSUS TRACT <br /> Owner's Name 40940, <br /> Address Phone <br /> City <br /> Contractor's Name -. •. ij�' <br /> -.License -Phone�' YS 3 � <br /> I� <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN '/ RECONDITION / / DESTRUCTIO <br /> `PUMP INSTALLATION <br /> ,. � . I MP <br /> Other REPAIR / / PUMP REPLACEMENT /_7 <br /> / / <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES �� PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINE - PRIVATE DOMESTIC- WELL'���PUBLIC.D � - OTHER <br /> INTENDED USE TYPE OF WELL STIC WELL 'I � <br /> I dustrial CONSTRUCTION SPECIFICATIONS ' <br /> �_ Cable Tool :Dia. of Well Ej,' vation _ <br /> - Domestic/private ! Drilled Dia. of Well Casing•,_ <br /> Domestic/public Driven <br /> Irrigation Gauge of Casing <br /> Gravel Pack Depth of Grout Seal --"- <br /> Cathodic Protection _k--__R_otar <br /> Disposal Y Type of Grout <br /> Other Information <br /> Geophysical Other InfIN <br /> F <br /> - Surface Seal Installed B <br />'UMP°INSTALTATTON: <br /> Contractor <br /> Type of Pump � <br /> H.P. ,M <br />'UMP REPLACEMENT: <br /> _ Stare Work Done <br /> UMP •.REPAIR ^� - <br /> / / State Work Done <br /> ES•TRUCT� I-N OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth I`- <br /> s�---- <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District � <br /> ad the State of California pertaining to or regulating well 'construction. Within FIFTEEN DABS <br /> Eter completion of my work on,a new well, I will furnish the San Joaquin Local Health District a f <br /> ELL DRILLERS REPORT of the well and notify them before putting the wellin use. The above <br />►formation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION ! <br /> JOR TO GROUTING AND A FIN_4 INSPECTION. <br />[GNED <br /> TITLE ' <br /> (DRAW PLOT PLAN ON. REVERSE SIDE) �M 1 <br />[ASE I <br /> ' FOR EPARTLMYNT USE ONLY " <br />'PLICATION ACCEPTED BYDATE <br /> .. i l Z <br /> iDITTONAL COMMENTS: , - 7, <br /> PHASE II GROUT INSPECTION <br /> SPECTION BY DATEPHASE .:III/FINAL `INSPECTION I� <br />' <br /> t INSPECTION BY . DATE <br /> may) i <br /> E H 1426 Rev. 1-74 / / x'77 ;. �' 2M <br />