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SAN JOAQUIN.LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 4 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. p <br /> THIS PERMIT EXPIRES 'l YEAR FROM DATE ISSUED Date Issuedy�-X9_77 <br /> i. (Complete In Triplicate) <br /> Application s. hereby made to.1the 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. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT ' i <br /> �--�0 <br /> Owner's Name � Phone <br /> Address l 2 �/Q City r <br /> r License ��` Phoney 0 �.3 <br /> Contractor's Name — 4 <br /> TYPE OF WORK (Check) : NEW WELL L_T DEEPEN/7 RECONDITION / DESTRUCTION %I <br /> PUMP INSTALLATION / / ' PUMP REPAIR '/ / PUMP REPLACEMENT A� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC',TANK SEWER LINES PIT PRIVY <br /> SEWAGE.DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTTER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ,I Cable Tool Dia. of Well Excavation <br /> Domestic/private !1 Drilled Dia. of Well Casing — 1 _ <br /> Domestic/public Driven Gauge of Casing ! <br /> Irrigation Gravel. Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other ' Other Information <br /> Geophysical Surface e Seal Installed <br /> By: <br /> _ . <br /> Su <br /> INSTALLATION: Contractor <br /> PUMP N ` <br /> .� _TypeJof-Pump_._ - - H.P. / <br />` PUMP REPLACEMENT: �State Work Done <br /> PUMP .REPAIR: / / IState Work Done <br /> DESTRUCTION OF WELL: Well (Diameter E 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 <br /> WELL DRILLERS REPORT-of the well and notify them before putting the. well in use. The above <br /> information isu to:the- st of- my owledge and belief. I WILL CALL FOR A GROUT INSPECTION. <br /> PRIOR TO GROUT AN A F INSPE ION. <br /> SIGNED TITLE <br /> W P PLAN 'ON RSE SI ;, f;.', <br /> a FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL ,COM49NTS <br /> PHASE II GROUT!-.INSPECTION PHASE III FINAL INSPECTION . <br /> INSPECTION BY DATE INSPECTION BY = — DATE <br /> 3/76 2m <br /> E H 1426 Rev. 1-74 R <br />