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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ' FOE OFFICE USE: .x.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77:,.7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued X77 <br /> F <br /> 11 (Complete In Triplicate) <br /> Application 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 with San Joaquin <br /> County Ordinance No. 1862 acid the Rules and egulations of the San Joaquin Local Health District. <br /> ,r <br /> JOB ADDRESS/LOCATION ; f Y <br /> CENSUS TRACT <br /> Owner's Name 1 r <br /> f Phone � - e <br /> Address fJ {p Q yr City <br /> Contractor's NameLicense Phone .. <br /> TYPE OF WORK (Check) : NEW WELL <br /> —/ DEEPEN /_/ RECONDITION /_/ DESTRUCTION /-7.PUMP INSTALLATION / PUMP REPAIR/ / PUMP REPLACEMENT /-7 <br /> Other ./ / <br /> DISTANCE TO NEAREST: SEPTIC�TANK SEWER LINES PIT PRIVY <br /> I SEWAGE �DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTTC WELL PUBLIC. DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL _ . � <br /> Industrial CONSTRUCTION SPECTFICATIONS �• <br /> — Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled <br /> Dia, of Well Casing Q <br /> Domestic/public t Driven Gauge of Casing <br /> Irrigation .1 Gravel Pack Depth of Grout Seal °\„$ <br /> Cathodic Protection I Rotary Type of Grout 0 <br /> Disposal Ti— Other.6 Other Information <br /> Geophysical ~ <br /> Surface Seal Installed By:- <br /> PUMP <br /> :PUMP INSTALLATION; Contiractord " t <br /> Type ofj-ump <br /> PUMP REPLACEMENT: /-/ State Work Dorie <br /> PUMP .REP <br /> / State Wofk Done <br /> E5 TRUCTION OF WELL: W 1 Diam" etter �� -20 <br /> / { <br /> escrib�'e�MaPPraximate Depth 7 ; <br /> t. aaui�Procedlirem- <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 -of my knowledge and belief. I WILL C FOR A GROUT I ION <br /> PRIOR TO OUTING FTNAL 'INS ECT ON. <br /> T7ES <br /> (��_ ' <br /> i DRAW PLOT PLAN ON RE EHSE k <br /> F FOR DEPARTMENT USE ONLY <br /> PHASE I � '/ <br /> APPLICATION ACCEPTED BY lit/ DATI —z 1`7 7 <br /> ADDITIONAL COMMENTS: _ <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY r - DATE z 77 <br /> E H 1426 Rev. 1-7472M , <br />