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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE; <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209)' 46.6-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z,l f'jp0 <br /> THIS PERMIT EXPIRES' l YEAR+ FROM DATE•ISSUED= Date Issued <br /> (Conplete In Triplicate) <br /> Application is iaereby made to the -San- Joaquin Local health District' for a permit to construct <br /> and/or install the work herein described. This application is-madelin compliance with 'San Joaquin <br /> County Ordinance No. 1862 •-and the Ryles and Regula ons t e San o quin Local Health District.- <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> - -- <br /> Owner's Name - h Phone <br /> :!�6 .L14 <br /> Address �' �� _ City <br /> Contractors Name <br /> License #26671 Phone <br /> t J <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN '/ / RECONDITION / / DESTRUCTION /_7 W <br /> i <br /> PUMP INSTALLATION /�'/ PUMP REPAIR / /; PUMP REPLACEMENT 127 <br /> Other /- 7 <br /> DISTANCE TO NEAREST: SEPTIC -TANK: SEWER LINES: PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT = , OTHER <br /> PROPERTY'LINE 4 PRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable 'Tool Dia.. of Well Excavation <br /> Domestic/private 'Drilled Dia. of Well Casing <br /> Domestic/public ; Driven Gauge of Casing 4� <br /> _ Irrigation Gravel Pack . Depth of Grout Seal �y <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Ixiformation <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor � r `c <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /_7 State Work Done <br /> PUMP .REPAIR: 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 andnotify 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 INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED }t , TITLE Y-261, <br /> D W PZ T PLAN 'ON REVERS <br /> E SIDE <br /> DEPAPTMENT USE ONLY <br />'CHA7EI ZY <br /> APPLICATION ACCEPT BY WE DATE <br /> ADDITIONAL COMMENTS: — <br /> PHASE II INSPECTION PHAS I/FI INSPECTION <br /> INSPECTION BY INSPECTION B DAT�/6 <br /> E H 1426 Rev. 1-74 3/76 2M' <br />