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SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOR OFFICEUSE: v 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 - <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. O� <br /> THIS! PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made toithe San Joaquin Local Health District far 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 andithe Rules and Regulations of the San Joaquin Local Health District. <br /> al <br /> JOB ADDRESS/LOCATION D G� .J % OqnCENSUS TRACT ' <br /> 4 <br /> Owner's Name /� �.1. d a �F Phone <br /> city .4 <br /> Address D J L U +[ <br /> �~� ' License ���/�7J� AD W- <br /> hone <br /> Contractor s Name <br /> �fit <br /> TYPE OF WORK (Check) : NEW WELL V<' DEEPEN / / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other <br /> r i <br />.DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> F 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.,... 4--Drilled Dia. of Well Casing <br /> Domestic/public ;} Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal �d <br /> '• Cathodic Protection --Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical- J Surface Sea! Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> — <br /> PUMP .REPAIR: /-7 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 is true to the best,o£ my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> I PRIOR TO GROU ING AND A UkALJNSPECTION. <br /> I SIGNED TITLE <br /> D�19w-.PMT PLAN 'ON REVERSE SIDE "r,; <br /> FOR DEPARTMENT USE ONLY <br /> PHASE T <br /> APPLICATION ACCEPTED BY DATE <br /> K <br /> ADDITIONAL. COMMENTS: <br /> PHASE II GROUT INSPECTION PRASE II /FINAL INSPECTION <br /> INSPECTION BY DATE 7 INSPECTION BY DATE <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 �""''�� <br />