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SAN JOAQUIN LOCAL HEALTH DISTRICT �f i <br /> FOk'OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, C �lif.. ! <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PERMIT Permit No. .-77- <br /> THIS <br /> 7THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �7� <br /> 6j (Complete In Triplicate) I <br /> Application is Aereby 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. 1 <br /> , �t <br /> JOB..ADDRES S/LOCATION'— �_3=� . Q9L_j CENT S~S TRACT <br /> Owner's Name _TU f Phone <br /> Address �- _ � '' .iiF Q City " 3 <br /> Contractor's Name �� fir[ �j Lice <br /> nd 1P PhonZ71/ti5 <br /> I <br /> TYPE OF WORK (Check) : NEW WELL /�EEPEN /°— RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION //-r PUMP REPAIR / / PUMP REPLACEMENT /7 f <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ;x k <br /> SEWAGE DISPOSAL FIELD /,("j CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVAT DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation .• <br />_�t3omestic/private s Drilled Dia. of Well Casing f <br /> Domestic/public t Driven Gauge of Casing <br /> Irrigation .1 Gravel Pack -Depth of Grout Sealer <br /> Cathodic Protection 1 l.---Rotary f.` Type of Grout �� ,C [ • <br /> Disposal i Other J`_ �Oth6r.�Information.-,: sR 1 <br /> Geophysical <br /> Surf <br /> Geophysical Seal:-Ins-talled` By: i <br /> . . ..K�_ —--- -- <br /> s <br /> PUMP INSTALLATION: Contractor <br /> Iype_of Pump V. H.P. . . . . <br /> PUMP REPLACEMENT.:,", ` � / '/ State Work;Done <br /> — . . E, E- --- -- <br /> _,...".. <br /> PUMP .REPAIR: __ ' /State Work Done <br /> DESTRUCTION OF WELL: '-well Diameter Approximate Depth <br /> !'Describe Material and Procedure t <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 DAY'S <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 puttingthe..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 GROUTING AND A FINAL. 1,NSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: r ° <br /> PHASE II GROUT INSPECTION PHASE I/FINAL INSPECTION <br /> INSPECTION BY DATE ; INSPECTION BY DATE - 4' <br /> f <br /> E� 'H 1426 Rev. 1-74 177 -. e, - i <br />