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1' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: •;.. <br /> G 1601 E. Hazelton Ave. , Stockton, Calif. <br /> O � Telephone: (209) 466-6781 <br /> -I- APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 77� <br /> Application is h � (Complete In Triplicate) - <br /> pp hereby made to the San Joaquin Local. Health District for d� �7 <br /> 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 /> q o lL'6' <br /> JOB ADDRESS/LOCATION y It J1 <br /> LF CENSUS TRACT <br /> Owner's Name - F�'T �/G OilB <br /> Phone <br /> Address <br /> City 7-0 f-TOIV - <br /> Contractor's Name C �, License #26Q7 <br /> Phone <br /> TYPE OF WORK (Check): NEW WELL '_W DEEPEN -/ / RECONDITION_/_� 'DESTRUCTION / 7 <br /> `" <br /> PUMP INSTALLATION � PUMP REPAIR/ / PUMP REPLACEMENT /-7 ) <br /> Other ?/ / O ' <br /> x Q <br /> DI ST TO NEAREST: SEPTIC .TANK SEWER LINES �} f PIT PRIVY <br /> SEWAGE +DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMEL DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial € Cable Tool Dia, of Well Excavation <br /> Domestic °'� <br /> /private Drilled Dia. of Well Casing <br /> g 0 <br /> Doiuestic/p�?blic.: E <br /> TF- <br /> Irrigation ation £ _ Gau e <br /> 4 Gravel Pack Depth of Grout Seal <br /> Pr <br /> Cathodic., otection Rotary Type of Grout ° <br /> Disposal --- / �' <br /> Other Other Information <br /> - - T�—•--. <br /> Geophysical <br /> Surface seal Installed B : ' <br /> . 4 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> .� <br /> PUMP REPLACEMENT: /_7 State Work Done <br /> PUMP .REPAIR: :/ / State Work Done 4 <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> - k <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 <br /> Putting the -well in use.information is true to the best of. my. knowledge and belief. I WILL CALL FOR A GROUTeINSPECTION <br /> above <br /> PRIOR TO GR ING D A INAL IN P CTION.SIGNED <br /> • TITLE <br /> DRAW:PL T PLAN ON RE LASE SIDE <br /> I <br /> PHASE I F R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY i3 <br /> ADDITIONAL COMMENTS: DATE a <br /> PHASE I ROUT NSPECTION PHASE FINAL INSPECTI <br /> QN <br /> INSPECTION BY E INSPECTION BY it/ <br /> ATE <br /> _:57 P <br /> E HI1426 Rev. '1-74 -y � rfllsn <br />