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SAID JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. w <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z-��-P <br /> d <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssueL--'� <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 Regulations of the San Joaquin Local Health District. <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> ��� a Phone <br /> Owner's Name <br /> 6 S --. �, City J?� <br /> Address o"`) <br /> /;,� r License 5'1 Phone <br /> Contractor's Name < <br />�. TYPE OF WORK'"(CY►ack): NEW WELL / E/ DEEPEN / / r RECONDITION, IrI DESTRUCTION-/ T <br /> PUMP REPLACEMENT <br /> PUMP INSTLATION/ / PUMP REPAIR <br /> AL / I <br /> Other 1_7 <br /> ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY q <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER . N� <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL (113 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> 4 Industrial Cable Tool Dia. of Well Excavation 1C� <br /> Domestic/private' Drilled Dia. _of, Well Casing <br /> Domestic/public Driven Gauge of 'Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Prote.ctiob Rotary Type of Grout <br /> Disposal <br /> Other,_____T_ Other Information <br /> Geophysical Surface Seal Installed FB : ,j <br /> PUMP INSTALLATION: Contractor <br /> . . <br /> E Type of.1. HP <br /> ! <br /> , ;a i <br /> PUMP REPLACEMENT; %% State Work Dane <br /> PUMP .REPAIR: / / StatetWork Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <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 <br /> WELL 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 /> PRIOR TO GROUTING D FIN TNSP ION. <br /> SIGNED TITLE ' <br /> (ARAW PZ'T PLAN 'ON RE ERSE SIDE) <br /> FOR DEPARTMENT USE ONLY 3 <br /> PHASE I DATE -� 7 <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE T I INAL NSPECTION <br /> PHASE II GROUT INSPECTION ATE - 2 <br /> INSPECTION BY DATE INSPECTION BY <br /> 3/76 2M <br /> E H 1426 Rev, 1-74 � - <br />