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SAN JOAQUIN LOCAL HEALTH DISTRICT 1 14 <br /> FOH OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> : <br /> Tele hone <br /> p (209) 466-6781 7 � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedflEC. 281977 <br /> (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 Regulat'ons of the S n Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 3 Z, CENSUS TRACT <br /> Owner's Name �rti+ v.�C, Phone <br /> Address { wA S' �`. City <br /> Contractor's Name ; .License 112Phone <br /> � � t <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / / RECONDITION /_/ DESTRUCTION /? <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LIMES/If&ff PIT PRIVY <br /> SEWAGE DISPOSAL FIELD _&Z�r_- CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE 701PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> .Domestic/private Drilled Dia. of Well Casing .� fi -- <br /> Domes•tic/public Driven Gauge of Casing Zef <br /> Irrigation Gravel Pack Depth of Grout Seal 5 <br /> Cathodic Protection 1 Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: =:Srr y <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP -REPAIR: / / 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 thewell in use.. . The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT AND A FINAL INSPECTION. <br /> SIGNED TITLE «,.. <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE /2 - <br /> ADDITIONAL COMMENTS: <br /> PHASE II OOUSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY D E <br /> E H 142E u�Yr_ . 1..7G l/1 / / n��7 2M <br />