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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> O O +I'TCE -jUSE: 1601 E. Hazelton Ave. , Stockton, Calif. V rS <br /> Telephone: (209) 466-6781 _ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No..7 /5 2-7, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued L )1 -77 <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. 18noo,_.l <br /> 62 and the Rules and Regulations of the San Joaquin Local Health District,JOB ADDRESS/LOCATION CENSUS TRACT <br /> Ownek's Name 1 - F Phone Nko,. <br /> Address % City � <br /> Contractor's Name License <br /> Phone <br /> ? <br /> i <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN -/ RECONDITION :/_-7---DESTRUCTION /_7PUMP INSOLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES /DDS 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 /> - X Industrial Cable Tool Dia. of Well Excavation p/W <br /> Domestic/private Drilled Dia. of Well Casing �� <br /> Domestic/public Driven Gauge of Casing _ T/141e99,A€, <br /> Irrigation Gravel Pack Depth of Grout Seal. <br /> Cathodic Protection x Rotary Type of Grout <br /> Disposal Other Other Information V4 <br /> Geophysical Surface Seal- Installed By: J? <br /> PUMP INSTALLATION: Contractor J <br /> Type of Pump H.P. . R <br /> PUMP REPLACEMENT: / / State Work Done, <br />,PUMP _REPAIR: : / /._ State_.Work Done <br /> DESTRUCTION 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 <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 putting the well in use.... The above <br /> information is true to the best of- my kriowledge,iand belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINW IN <br /> SIGNED TITLE <br /> (DRAW fLOT PLAN ON' ERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY K` /`� DATE r �� <br /> ADDITIONAL COMMENTS: <br /> PHASE �I GROU INSPECTION PHASE II V FINAL INSPECTION <br /> INSPECTION BY E f f z�'�f INSPECTION BY ,/ DATE 4 <br /> 6012.[ +.% - / <br /> E H l la 2 6 sz,�.� _7 ? � . ✓ '.� � � /� iii'!7 2M�. <br />