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i f� c. 1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton Calif. i3 <br /> M Telephone:. (209) 466-6781 <br /> APPLICATION FOR WELL'!CONSTRUCTION OR PUMP PERMIT Permit No.11`0 <br /> I �6 f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ��✓7 <br /> r ; . <br /> '# (Complete In Triplicate) 4 <br /> Application is Aerebyiimade 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 Jpaquinf <br /> County Ordinance No. ,1.862 and the Rules and �Regulatipns of/the <br /> San Joaquin Local Health District. <br /> JOB ADDRESS/ ATION .1 J CENSUS TRACT <br /> Owner's Name Fho <br /> Address / ! F y <br /> a <br /> Contractor's Name "" License h <br /> 3one <br /> TYPE OF WORK (Check) ::, NEW WELL/ / DEEPEN,p/-7 RECONDITIO' ,/__7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR //Y PUMP REPLACEMEN__ _7 lS� <br /> Other '/ / !I -` 1 a <br /> DISTANCE TO NEAREST: SEPTICHTANK 'SEWER-LINES PIT PRIVY <br /> iSEWAGE'DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> „ PROPERTY LINE - PRIVATE DOMESTIC WELL _ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS' <br /> Industrial t Cable Tool Dia, of Well Excavation <br /> Domestic/private [ Drilled € Dia. of Well Casing <br /> Domestic/public:' Driven Gauge of Casing { <br /> Irrigation 1.1 Gravel Pack Depth of Grout Seal <br /> Cathodic Protection ;i Rotary E Type of Grout <br /> Disposal I Other kl Other.,.Information R` <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION. Contractor <br /> Type of Pump p ` H.P. . . . <br /> _ � 1 <br /> PUMP REPLACEMENT: / / State Work Donel'� <br /> It i <br /> PUMP :REPAIR: ;�, -State Work--Do <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 uy work on a new well, I will furnish the San Joaquin Local Health District' a - <br />€ WELL DRILLERS REPORTI;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 FINAL' INSPECTION. <br /> SIGNED _ r r TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE:, I � <br /> I <br /> APPLICATION ACCEPTEDl!BY DATE , <br /> ADDITIONAL COMMENTS: A <br /> PHASE. 11, GROUT INSPECTION PHAS III/F AL INSPECTION <br /> I INSPECTION BY f! DATE INSPECTION BY DATE z3 -72 <br /> F - <br /> t <br /> ' r <br /> k E H 1426 Rev. 1�'-74 <br />