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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209), 4:66-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,6.-2107 <br /> r <br /> THIS--PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,I- <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 Joaquir <br /> County Ordinance No. 1862 and the ules and Regulations of the oaquin Local Health District. <br /> I <br /> JOB ADDRESS/LO ION ENSUS TRACT <br /> f <br /> E Owner's Name Phone �Fc3 <br /> Address ��rs 9_1 City - <br /> Contractor's Name � r/ License # Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /_/ DESTRUCTION <br /> AL <br /> PUMP INSTLATION/ / PUMP REPAIR / / PUMP REPLACEMENT <br /> 97 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 1� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> .Domestic/private Drilled Dia. of Well Casing U <br /> _ Domestic/public Driven Gauge of Casing G, <br /> P -Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> t � Geophysical Surface Seal Installed By: <br /> PUMP :INSTALLATION: Contractor n <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Woxk <br /> V� <br /> 1°'PUMP-'-REP91R­-.--- .—h P—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.1best of my..knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> `SIGNED ' r TITLE _44f <br /> /),—.tr <br /> od <br /> *DRAW PI, 'I' PLAN 'ON REV-9RSE SIDE) <br /> y FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY s DATE 4-12 -� <br /> ADDITIONAL COMMENTS: i / <br /> PHASE II GROUT INSPECTION IfRASE III./FINAL INSPECTION <br /> INSPECTION BY ! DATE INSPECTION BY DATE r 6 <br /> E <br /> 3M 2M <br /> H 1425 Rev. 1-74 <br /> ,,�" <br />