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` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE.'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. v <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Perm #01. Z7--,-8k,� <br /> i <br /> C THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued E,)s 77 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> s and/or install the work herein described. This application is made in compliance with San Joaquin' <br /> C_ount.y_Ordinance No_...1862-and the Rules and Regulations of the San Joaquin Local Health District. -' <br /> r <br /> JOB ADDRESS/LOCATION C..d O(!s 7,L w a%� . <br /> -. fie'/ 3 CENSUS TRACT <br /> /r > r . <br /> Owner's Name7 <br /> � .e Phone Y-ot 3 <br /> I V V <br /> Address l ;� a City <br />` . Contractor's Name <br /> z License # Phone <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /% RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / / ` PUMPIREPAIR / / PUMP REPLACEMENT /7 <br /> 0 <br /> Other#/ / E <br /> ,DISTANCE_TO NEAREST: SEPTIC �TANK* SEWER LINES f PIT PRIVY <br /> SEWAGE 'DISPOSAL FIELD CESSPOOL/S AGE PIT OTHER <br /> PROPERTY LINE/dOPRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL �-- j <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> X Domestic/privateDrilled.. kDia. of Well Casing <br /> Domestic/public Driven 'Gauge of Casing ` III <br /> r Irrigation Gravel Pack.- Depth of Grout Seal b R <br /> Cathodic Protection `.Rotary Type of Grout " =' <br /> Disposal- Other Other Information <br /> Geophysical `Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump < H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,REPAIR: / / State Work Done , <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth f <br /> Describe Material and -Procedurez <br /> I hereby agree to comply with' all laws and regulations of the San Joaquin Local Health District i <br /> and the State of California pertaining to or regulating well 'construction. Within FIFTEEN DAIS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Distriet 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 /> PRIOR TO GROUTING AND A FINALIINSPECT ION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) 1 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY : <br /> DATE ' , ^,1-/-7 <br /> ADDITIONAL COMMENTS: } <br /> PHASE II GROUT INSPECTION PHASE N P I ! <br /> INSPECTION BY DATE INSPECTION BY TE <br /> E H 1426 Rev. 1-74 , 1177 <br />