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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOr1:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> a y, Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7jC FWW <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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/LOCATION ZQo` CENSUS TRACT <br /> a <br /> Owner's Name Phone , <br /> Address City . <br /> 4"sfr.L' <br /> 91fd .6` <br /> Contractor's Name License # Apo j2 c/ Phone k-IZt-1-4 <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /7 RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR 1_7 PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC'TANK /SG SEWER LINES PIT PRIVY \ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER Q <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL (� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS p, <br /> Industrial e Cable Tool Dia. of Well Excavation <br /> r v <br /> Domestic/private Drilled Dia. of Well Casing 1!2 ' a <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of, Grout <br /> Disposal � , . - —_�. Other Other Information <br /> Geophysical ; Surface Seal Installed BY' <br /> PUMP INSTALLATION: Contractor <br /> Type o£•Pump T_ H.P. <br /> PUMP REPLACEMENT: , / / State Work Done - - <br /> . . -... ...� F <br /> PUMP :REPAIR: / / `State Work Done <br /> - .-- <br /> ti <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.knowledge and belief. I WILL CALL FOR A GROUT INSPECTIO <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 4 ­el-7 <br /> ADDITIONAL COMMENTS: <br /> P46�W, II RO INSPECTION P II F INSPECTION <br /> INSPECTION BY DATE - INSPECTION B �4 4 AATE <br /> 6/ 74, <br />{ E H 1426 Rev. 1-74 rr - 4/75 2M <br />