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li <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORiOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 / <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No,7 <br /> THIS PERMIT EXPIRES' l YEAR FROM DATE ISSUED Date Issued f,3 <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 /> JOB ADDRESS/LOCATIONCENSUS TRACT <br /> b <br /> Owner's Name r Phone -464 1 V <br /> Address f C>K' City <br /> Contractor's Name. License #2_ Phane <br /> ` r <br /> TYPE OF WORK (Check): NEW WELL IST DEEPEN/_-7 RECONDITION /-7 DESTRUCTION 17 <br /> - 17� <br /> PUMP INSTAL TION PUMP REPAIR /-7—pump REPLACEMENT <br /> Other <br /> i <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 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation F Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal ii Other "Other Information <br /> Geophysical "�� <br /> Surface Seal Installed BY: w <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /;�/ State Work Done i <br /> PUMP '.REPAIR: <br /> State Work Done <br /> ES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District I` <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 Saiz Joaquin Local Health District a <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 AND A FINAL INSPECTION, <br /> SIGNED II TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> :i FOR DEPARTMENT USE ONLY <br /> PHASE I :; k <br /> APPLICATION ACCEPTED BY, DATE r--70 -7 <br /> ADDITIONAL COMMENTS: <br /> PHASE I GPLAV INSPECTIO PHASE I:U/FINAL INSPECTION <br /> INSPECTION BY DATE 1 INSPECTION BYDATE <br /> I E H 1426 Rev. 1-74 1-74 2M <br />