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SAN JDA UI - _-- -- <br /> F0$jQFFICE USE: N LOCAL -HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7G /Q� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ' (Complete In Triplicate) �-=�-7� <br /> Application is hereby made to the San Joaquin Local Hearth District for a permit to construct <br /> anti/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin, Local Health District. <br /> JOB ADDRESS/LOCATION 7 <br /> 'v CENSUS TRACT <br /> Owner's Name ! <br /> Phone . <br /> Address c <br /> City <br /> Contractor's Name JAd� <br /> License Phonea <br /> r <br /> TYPE OF WORK (Check) NEW WELL�I�>..DEEPEN '-/��RECONDI•TIQN•-/?DESTRUCTION-/' <br /> PUMP INSTALLATION / I PUMP REPAIR 17 PUMP REPLACEMENT <br /> Other S7 <br /> DISTANCE TO NEAREST; SEPTiC TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSP 00 L/SEEPAGE PIT <br /> OTHER I <br /> PROPERTY LINE - PRIVATE .DOMESTIC WELL ' PUBLIC DOME5TIC WELL f <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS � <br /> Industrial Cable Tool Dia. of Well Excavation . ,•. � <br /> Domestic/private Drilled <br /> Domestic F 'Dia. of Well Casing <br /> /public - - Driven 41 Gauge o£-Casing%,$ _V <br /> _ Irrigation .� , _ �. <br /> Gravel Pack. :'1_­7Depth of Grout Seal - <br /> Cathodic Protection Rotary Type--of "Grout s <br /> Disposal Other <br /> —Geophysical --.�._ Other Information: � <br /> Surface-Seal Installed B : <br /> PUMP INSTALLATION: Contractor <br /> Type -of,Pump <br /> H.P. <br /> PLS REPLACEMENT: State Work Done <br /> E <br /> y PUMP 'REPAIR: .LL —.State Work Done, <br /> ES;TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 •REPQRT 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 /> PRIOR TO'GROUTING AND FI AZ INSPECTION, <br /> SIGNED : <br /> TITLE <br /> {DRAW PLOT PLAN ON REVERSE SID <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE /Q -/, 7,4 <br /> PHASE -I•I .GROUT INSPECTION <br /> INSPECTION BY. u DATE PHAS I AL INSPECTION <br /> - � ._ INSPECTION BY 9 ATE <br /> ' E H 1426 Rev., 1-74 <br /> 1-74 9M <br />