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m � SAN JOAQUIN LOCAL HEALTH DISTRICT . Ifo -7s'w <br /> S <br /> 1601 E. Hazelton Ave. , Stockton, Calif. !pr p <br /> FOS OFFICE USE: <br /> # 'Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.��- <br /> THIS PERMIT 'EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> s (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 and the Rules and Regulations of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION. <br /> ✓G�� �rr+�- r -� . i! ! CENSUS TRACT <br /> Phone <br /> owner's -Ame '4:_;9 � <br /> Address � � ts .. City <br /> r <br /> License # /JJ3 Phone, <br /> Contractor's Name " <br /> 1 ` <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / RECONDITION / ./ DESTRUCTION /-7 <br /> PUMP -INSTALLATION /_/ PUMP REPAIR /,/ PUMP REPLACEMENT /? <br /> Othe3 / <br /> DISTANCE TO NEAREST: SEPTIC, TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOLISEEPAGE PIT OTHER <br /> i PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL -� <br /> INTENDED USE iTYPE OF WELL CONSTRUCTION SPECIFICATIONS D <br /> Industrial I Cable Tool Dia. ,.of Well Excavation <br /> Domestic/private. I Drilled- Dia, of Well Casing <br /> Domestic/public # Driven Gauge of Casing <br /> �Zt Irrigation Gravel Pack Depth of Grout Seal" <br /> Cathodic Protection Rotary Type of Grout <br /> p <br /> Geophysical _ Surface Seal Installed By: <br /> PUMP INSTALLATION: Contactor off d <br /> Type of Pump 17 <br /> H.P. <br /> / Work Done -• <br /> PUMP: REPLACEMENT: / / State Wo / <br /> PUMP.-.REPAIR: /J�/ <br /> State Work Done, <br /> h <br /> DES-TRUCTION OF WELL: Well. Diamater Approximate •Depth <br /> Describe Material and Procedure <br /> Z herebylagree to comply with all laws and regulations of the San Joaquin Local Health Distract <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> k 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 is true to the hest of my n'wl dge a d lief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUT NG AND A FINAL I N. <br /> i SIGNED is a ITLE — <br /> iLOT P ON RE RSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE -`��-77 <br /> APPLICATION ACCEPTED -BY <br /> ADDITIONAL. COMMENTS: ' <br /> PHASE II FmOUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE. INSPECTION BY DATE /0•--�7-7 <br /> — 6/77 . 2M <br /> F:-H 1426 -Rev. - 1-74 <br />