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SAN JOAQUIN LOCAL-.HEALTH DISTRICT <br /> } FOArOk'FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telaphone: . fi(209) 466-6781 / !E <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR-FROM•DATE ISSUED Date Issued S.-90-7v <br /> (Complete In Triplicate) <br /> Application is hereby made tolthe San Joaquin Local. Health District for a permit toconstruct <br /> and/or install theworkherein described.. This application •is made in compliance with San Joaquin <br /> County Ordinance No.,J862. and: the Rules -arid Regulations of the> San Joaquin Local Health District. <br /> JOB ADDRES S AOCATION "�r01 ,0.P _ --Ato,( CENSUS TRACT <br /> Owner's Name : # , <br /> �� Phone <br /> Address •� -�R .� 6r,-a. n ay i . City . <br /> Contractor's Name License # -Phone <4C),76 74 <br /> 'TYPE OF WORK (Check): . NEW WELL/_T DEEPEN -/? RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT <br /> Other '/ / <br /> DISTANCE TO .NEAREST: SEPTIC TANK . SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD' CESSPOOL/SEEPAGE PIT OTHER <br /> ,PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS r <br /> " Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private j Drilled Dia. of Well Casing ` <br /> >t_ Domestic/public i Driven Gauge of Casing <br /> Irrigation • i Gravel Pack Depth of Grout Seal <br /> Cathodic Protection` 0 Rotary Type of Grout <br /> Disposal ' _ - i Other Other Information <br /> Geophysical 'Surface Seal Installed By: ` <br /> PUMP INSTALLATION: Contractor . <br /> Type of Pump H.P. / <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'REPAIR: /� State Work Done _ � <br /> 29S.'TRUCTION OF WELL: Well Diameter Approximate Depth <br /> GE <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 a <br /> WELL DRILLERS REPORT of the well acid notify them before putting.the..we11 in-use.. The above <br /> -information is true to the-best of. my knowle a and bel ef. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOG G AND A FINAL INSPECTION. <br /> SIGNED <br /> E DRAW P =T 0 ER SIDE <br /> a FO PARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS., <br /> PHASE 'II GROUT INSPECTION. PHASE Ii INAL INSPECTION <br /> INSPEC'T'ION BY DATE INSPECTION BY �� DATE Zi�� 7 <br /> i `3 E H 1426 Rev. 1-74 1-74 2M <br />