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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,�9d Ad <br /> 7_9 S1 <br /> THIS PERMIT. EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> E (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 ��cjl(� -- _ CENSUS TRACT , <br /> Owner's Name h 7, �t� omaPhone <br /> Address City c <br /> , License 4 Phone l� <br /> Contractor's Name //'�� <br /> TYPE OF WORK (Check) : NEW WELL '/9DEEPEN / / RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION </ PUMP REPAIR %/ PUMP REPLACEMENT /? <br /> Other Y-7 <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL MELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINEO PRIVATE DOMESTIC WELL PUBLIC~DOMESTIC WELL L 1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _ Cable Tool Dia. of Well Excavation _ ld `r � . <br /> Domestic/private 1 Drilled Dia. of Well Casing - � I <br /> Domestic/public Driven t Gauge of Casing 1-2— <br /> Irrigation Gravel Pack Depth of Grout Seal U <br /> Cathodic Protection ! SC Rotary Type of Grout �e _ U <br /> . <br /> 'Disposal 'i} Other Other Information <br /> Geophysical Surface Seal Installed By: ,, <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. /lam <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / '/ -State Work Done <br /> r � ,i• <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> +Describe Material and Procedure <br /> i . <br /> } <br /> I hereby agreelto 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 raork; on a new-well, I will furnish the . San Joaquin Local Health District <br /> WELL DRILLERS REPORT of well and notify them before putting the .well in use. The above <br /> information is' true the best of my..knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTI F ECT <br /> TITLE- <br /> SIGNED <br /> DRAW PLID PLAN ON REVERSE SI <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 7 . <br /> APPLICATION ACCEPTtD BY DATE <br /> ADDITIONAL COMMENTS: " .., <br /> '- PHASE II' GRO TfINSPECTION PHASE III/FINAL.;,INSPECTION ; <br /> INSPECTION'BY . (DATE '. "�_ INSPECTION BY / DATE <br /> s � <br /> t 3/76 2M <br /> E H 1426 Rev. '1-74 _ <br />