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h <br /> SAN JOAQUIN LOCA MALTH DISTRICT <br /> FO'! OFFICE USE: ✓ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> I Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7h- 1,13 fv <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued .�'-/j J,d <br /> (Complete In Triplicate) <br /> Application is hereby trade toIthe 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 Ord nance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. . <br /> AleA <br />.JOB ADDRESS/LOCATION ENSUE TRACT ' <br /> Owner's NamePhone 3/ <br /> J <br /> Address i City '. <br /> Contractor's Name License # ` Phone 3�r T;>d <br /> ..�+ _._ <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / T -RECONDITIDN .DESTRUOTIdN_/_i f,� <br /> m PUMP4 INSTALLATION / / PUMP. REPAIR /� PUMP REPLACEMENT � .. <br /> Other �. .. <br /> DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES 75- - PIT PRIVY <br /> SAL <br /> SEWAGE DISPOFIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE 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 �� <br /> Domestic/public Driven Gauge of Casing .411A_ At <br /> �w <br /> Irrigation Gravel Pack Depth of Grout Seal. <br /> Cathodic Protection Rotary , Type of Grout ' <br /> Disposal Other Other Information .. <br /> Geophysical Surface SealV:Installed B : of Cs <br /> PUMP INSTALLATION: - Contractor , <br /> Type .of Putter H.P. <br /> _ •� F <br /> PUMP REPLACEMENT: • / / State Work Done <br /> PUMPate Work Done < <br /> PE&TRUCTION-OF'WELL: ...,,_Well Diameter 4 Approximate Depth <br /> ti <br /> Describe-;Material and Procedure I <br /> + i <br /> I hereby agree to comply�with�all"laws and regulations of the San -Joaquin Local Health District <br /> and the State of Califbrniam pert firing tlofor •regulating well'construction. Within FIFTEEN DAYS <br /> after completion'o?my work on a new well,'vI willfurnish the San 'Joaquin Local Health District a <br /> WELL DRILLERS REPORT'„of the well anis 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 A FINAL INSPECTION. <br /> SIGNED 44 TITLE ': <br /> (DRAW PIAT PLAN ON REVERSE�SIDE <br /> FOR DEPARTMENT USE ONLY ! <br /> PHASE I— <br /> APPLICATION ACCEPTED BY T' DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE cIP -ori3'7:; INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 o f -. 4/75 2M <br />