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{ FOE SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: ' 1601 E. Hazelton Ave, , Stockton, Calif. <br /> " Telephone <br /> (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> �r? P <br /> THIS. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ' Date .Issued ----------�-� <br /> Application �s �� (Complete In Triplicate) <br /> 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 Joa <br /> f n <br /> County Ordinance _No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> JOB ADDRESS/LOCATION <br /> f - — CENSUS TRACT <br /> Owner's Name <br /> ®i�aZAN <br /> Phone <br /> Address / tc 76 - <br /> City . <br />` Contractor's Name <br /> License V <br /> Phone ' <br /> f <br /> TYPE OF WORK (Check) : NEW WELL t <br /> / / DEEPEN '/_/ RECONDITION /-7_ DESTRUCTION /_7 <br /> PUMP INSTALLATION —/ / PUMP REPAIR /Xf PUMP REPLACEMENT /-7 <br /> Other Ll <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY <br /> kSEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> PROPERTY. LINE - PRIVATE DOME <br /> INTENDED USE PE STIC WELL PUBLIC DOMESTIC WL ,� <br /> TYOF WELL <br /> Industrials * Cable Tool CONSTRUCTION SPECIFICATIONS <br /> Dia <br /> Domestic —~-,-- . of Well Excavation {� i <br /> /private i Drilled Dia. of Well Casing <br /> Domestic/public 1 Driven v1 <br /> Irrigation Gauge of Casing <br /> ,.1 Gravel Pack Depth of Grout Seal <br /> Cathodic Protection i{. Rotary Type of Grout <br /> Disposal 1 Other Other Information <br /> Geo phy s i c al ------- <br /> Surface+ Seal Installed B : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> _ ! .� <br /> PUMP REPLACEMENT: <br /> // / State Work Done <br /> PUMP .REPAIR: i <br /> State Work Done <br /> IES•TRUCTION OF WELL: WeZI Diameter <br /> Describe Material„and. ,P.rocedur.e...� .'. Approximate Depth <br /> ry^- _ ---n <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local HealthTi—strict <br /> and the State of California pertaining to, or regulating well construction. Within FIFTEEN DAYS <br /> Iter completion of my' work on.a new well,., -1 will furnish the San Joaquin Local Heal.th. District a , <br /> TELL DRILLERS REPORT of the"we11 and notif them before Puttingthe- well in use. The above <br /> nformation is true to the Best of my knowledge and belief.,' <br /> RIOR TO QN .I WILL CALL FOR A GROUT INSPECTION <br /> GROUTING AND A FINAL- -- SPE CTI <br /> IGNED I <br /> TITLE <br /> Pe .t' <br /> (D P T 'P AN ON R ERSE SIDE) <br /> RASE I DEPARTMENT USE,.ONLY <br /> PPLICATION ACCEPTED BY r.�o <br /> DDITIONAL COMMENTS: 1 DATE <br /> PHASE II GROUT INSPECTION PHASE IIT/FINAL INSPECTION <br /> vSPECTION BY DATE ..INSPECTIONPBY <br /> . DATE <br /> E, H 1426 Rev. ' 1-74 1 J77 + �u <br />