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FOR.OFFICE UUSE• SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7..5= 5-474c,' <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date '� 6/r� <br /> Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Ilealth 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/LOCATION <br /> Owner's Name <br /> CENSUS TRACT <br /> ���`�� � T�� <br /> Phone <br /> Address < I <br /> City <br /> �7 <br /> Contractor's Name �� ��L . c — 1 �} License # Phone <br /> TYPE OF WORK (Check) : NEW WELL -/?, DEEPEN -/ RECONDITION /? 'DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR/? PUMP REPLACEMENT f�7j <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - <br /> SEWAGE DISPOSAL FIELD PTT PRIVY <br /> PROPERTY LINE PRIVATE DOMES TIC SWELL <br /> IENDED USTYOF WELL `SEEPAPUBLIC DOMESTIC E PIT WELL <br /> NTE PE CONSTRUCTION SPECIFICATIONS � ' <br /> Industrial ,_� Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia; of Well Casing � I <br /> Domestic/public Driven <br /> Irrigation " ` — _ Gauge of Casing <br /> Gravel Pack Depth of Grout Seal f <br /> Cathodic Protection Rotaryv <br /> Disposal Type of Grout <br /> Geophysical ion <br /> ,�_ Other Other Informat ! <br /> Surface Seal Installed B <br /> PUMP INSTALLATION.- ContractorC L i()EL_L <br /> Type of Pump P T <br /> H.P. Y7— <br /> PUMP <br /> 7PUMP REPLACEMENT: S tate Work bone L <br /> PUMP :REPAIR: J <br /> • / / State Work Done - a <br /> t <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> i <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> Ind the State of California pertaining to or regulating well."construction. Within FIFTEEN DAYS <br /> ifter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br />+TELL DRILLERS REPORT of the well and notify them before putting. th ..well. in.use.. . The above <br /> Information i true to the-best of. my k owledge and belief. I WIL _ L.:F A GRO NSP CTION <br />'RIOR TO GROUT AND A F I CTIO <br /> i IGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br />'RASE I FOR DEPARTMENT USE ONLY <br /> J'P�A ION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE_Z2117 <br /> PHASE II GROUT INSPECTIO PHASE I I FI AL INSPECTI <br /> NSPECTION BY _ DATI: <br /> INSPECTION BY <br /> DATE <br /> E H 1426 Rev. 1-74 <br />