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' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOi'pFFIEE1�,=SE: 7601 E. Hazelton Ave. , Stockton, calif .. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> EI - . <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> il Date Issued ,'/'—//- 7,f/ <br /> Application is hereby made t, the San (Jain Complete Triplicate)In <br /> Local District for a permit to cons <br /> truct <br /> and/or install the work herein described. This .applica.tion is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and <br /> t <br /> _ Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION c�lj ac _ <br /> . � CENSUS TRACT <br /> Owner's Name �t� � <br /> r Phone - � <br /> Address K <br /> City <br /> Contractor's Name <br /> ( License # 967/ Phone r- <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN ' <br /> RECONDITION / / DESTRUCTION /_ <br /> .PUMP INSTALLATION / I PUMP REPAIR / PUMP REPLACEMENT /? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC 'TANK <br /> 1yp',+� SEWER LINES PIT PRIVY J <br /> SEWAGE ;DISPOSAL FIELD _LZJO � o�.��•7� /�ff-�' O�tl�� <br /> ` CESSPOOL/SEEPAGE PIT OTHER / <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL ©r <br /> INTENDED USE TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS f. <br /> Cable Tool Dia. of Well Excavation <br /> Domestic/private <br /> Domestic Drilled Dia. of Well Casing •� <br /> /public 3 Driven Gauge of Casing —�`�L���-_� <br /> Irrigation t Gravel Pack Depth 'of Grout Seal <br /> Cathodic Protection I ± <br /> OtherRotarType of Grout <br /> Disposal GeophysicalOther Information <br /> ------- <br /> E . - Surface Seal Installed B : <br /> PUMP INSTALLATION; Contractor <br /> Type of: Pump <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: S - _ - - - <br /> tate Work Done - - - = <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with ,'a11 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 /> 4ELL 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 />'RIOR TO GRO TING AND A FINAL INSPECTION. <br /> SIGNED <br /> TITLE f <br /> ( W PLOT PLAN ON ERSE SIDE) <br />'HASE I FOR DEPARTMENT USE ONLY <br /> IPPLICATION ACCEPTED BY x��l <br />,DDITIONAL CMENTS: DATE <br /> PHASE II GROUT INSPECTION — <br />.NSPECTION BY DATE PHASE II / NAL INSPECTION <br /> INSPECTION BY DATE - <br /> R H 1426 Rev. • 1-74 0, 77 9MF <br /> - - -�-- -- <br />