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SAN JOAQUIN LOCAL HEALTH. DISTRICTg�-� <br /> FOE OFFICE USE: _ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781' i. <br /> APPLICATION FOR WELL CONSTRUCTION OR-PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued(22-16-'� <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. 18//62 and the ulear, and Re latio of the San Joaquin.,Local Health District. <br /> r <br /> JOB ADDRESS/LOCATION ✓ / CENSUS TRACT <br /> t Owner's Name s� ne ✓ �� <br /> Address /v / / City <br /> Contractor's Name License,� 3 7�Phoneo "4 :'�r� <br /> r TYPE OF WORK (Check) : NEW WELL . DEEPEN /�_/ RECONDITIONS%_/ T I)E R d "7'TION ' <br /> }-. PUMP INSTALLA'T'ION / / ; PUMP REPAIR I / PUMP REPLACEMEN - a <br /> •,. Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT-PRIVY- <br /> SEWAGE <br /> ITPRIVYSEWAGE DISPOSAL,FIELD-- CESSPOOL/SEEPAGE PIT ' OTHER i <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL. ' <br /> INTENDED USE i1TYPE OF WELL CONSTRUCTION SPECIFIC 0 $ <br /> Industrial Cable 'Tool! Dia, of Well Excavation ; <br /> y Domestic/private i Drilled r - Dia. of Well Casing ' <br /> Domestic/public Driven Gauge of Casing• t <br /> Irrigation s '�Gravel. Pack - Depth of Grout SeaCj <br /> Cathodic Protection 1=-Rotary Type of-,Grout ( ` <br /> Disposal Other Other Information ' t w <br /> Geophysical y Surface Seal Installed B : \� <br /> �. <br /> PUMP INSTALLATION: ~Contractor � 'x <br /> Type of Pump ) H.P. -- <br /> C J <br /> PUMP REPLACEMENT: . /�` � State Work Done <br /> �PUbff REPA1M �.�� :,''�/ /' Sime Work`-Done^--- <br /> DES-TRUCTION OF WELL: Well Diameter (��/ �' ° Approximate Deptr. <br /> escri e`Materia and Pro ur.e <br /> r v1 <br /> I hereby agree to comply WAh al1' 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 'Nealth 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 INSP_5jQZION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION, <br /> SIGNED TITLE <br /> (DRAW-PL•T'" PLAN 'ON REVERSE SIDE <br /> �- FOR DEPARTMENT USE ONLY <br /> k PHASE I <br /> APPLICATION ACCEPTED BY � _ "! x DATE /LI7� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT IRSPECTION°""�"`/---"- T _°'_ PHASE IIT FINAL INSPECTION <br /> INSPECTION BY DATE C � IIVSPECTION BY DATE <br /> E H 1426 Rev, 1-74 <br /> • 76 2M <br />