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SAN JOAQUIN LOCAL, HEALTH DISTRICT <br /> FOE.OFFICE USE 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> k <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUERDate Issued 3 l6 7! <br /> Application isiereby made t (Complete In Triplicate) <br /> o the San Joaquin Local Health District for a permit to construct <br /> loAt <br /> or install .the work herein described. This application is. made in compliance with San Joaquin <br /> tOrdinance No. 1862 a d the Rules Regulations of th San Joaquin Local Health District. <br /> 57 <br /> $S/LOCATION t <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone a <br /> Address Q 7dO` <br /> City <br /> Contractor's Name <br /> License <br /> `.a^'r...w....-.,,:er}.,�-.,wee...r�,T...,o,n,.ns+.--,_=�•s,,,.,-_. _ _ - _ - - <br /> 1 <br /> TYPE OF WORK (Check) : NEW WELL /% DEEPEN/% RECONDITION /_7 DESTRUCTION /_7 r <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY } <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ,mss <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL C <br /> .INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 3 <br /> Industrial [ Cable Tool Dia, of Well Excavation <br /> Domestic/private <br /> I Drilled Dia. of/Well Casing <br /> Domestic/public I Driven Gauge of Casing <br /> Irrigation I Gravel Pack Depthh of Grout Seal <br /> Cathodic Protection Rotary '—Type of Grout <br /> Disposal t Other t �Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump --¢ <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work Done <br /> DES-TRUCTION OF WELL: Well Diameter E <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with all laws and regulations of the ;an 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 />?RIOR TO GR UTING AN A'� NAL INSPECTION. <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE; ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY s <br /> ADDITIONAL COMMENTS: DATE�8 <br /> PHASE II GROUT INSP TION PSE /FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION B!HA <br /> DATE — S'$' <br /> E H 1426 12av_ 1_7i � USD u f'"` C0 ► <br />