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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOpi r Pk'ICE USE: 1601 E. Hazelton Ave. , Stockton, _Calif. <br /> -- Telephone: (209) 4566781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,7 <br /> Ij <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7 <br /> (Complete In Triplicate) I <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 :Wade in compliance with San Joaquini <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> II JOB ADDRESS/LOCATION5�•-�-7 ���� <br /> CENSUS TRACT <br /> II Q_ Phone <br /> Owner's Name <br /> Address S"�— ZEE' r`f City <br /> i <br /> Contractor's Name a,G/ 4 License # /r�7a!Phone 2-7C <br /> ' <br /> it <br /> I-.� <br /> TYPE OF WORK (Check) : NEW WELL /� DEEPEN /? RECONDITION L DESTRUCTION / <br /> PUMP INSTALLATION j / FUME' REPAIR IGS'PUMP REPLACEMENT I=T <br /> ti <br /> .. . Other <br /> I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> ` SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> t 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 /> k - Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of..Casing: .. Rv <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 of Pump H.P. <br /> PUMP REPLACEMENT: L_/' . State Work Done <br /> PUMP :REPAIR: LW ! State Work Done �' /.�C62 - ..-- <br /> "ES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and. Procedure <br /> I hereby agree ree 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 d belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSP <br /> SIGNEDITLE <br /> r D L PLAN ON ERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASEAI,716INSPECTIONPRASE III FIN INSPECTIO <br /> INSPECTION BY ATE INSPECTION $Y ATE <br /> 7V f4l <br /> It ^ E H 1426 Rev. 1-74 __ '1_1-74 2M <br />