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VI)d <br /> SAN JOAQUIN LOCALiHEALTH DISTRICT <br /> FOArOFFICE USE; 1601 E. Hazelton Ave. , :Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 a 9�2'fa <br /> IIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _ 3- <br /> r� (Complete. Tn: Triplicate) <br /> Appliedtion is hereby made to the San J:oaquiD.-Local Health District for a permit to construct I <br /> and/or install the work Herein described. This application is made in compliance with San Joaquink <br /> County Ordinance No. 1862 and the-Rules and Regulations of the San Joaquin .Local Health Distridt. <br /> JOB-ADDRESS/LOCATION0I-z7q <br /> CENSUS TRACT <br /> Owner's Name devit ,� �p 4 �;OM s Phone <br /> Address 2 Z 3 T S, City <br /> Contractor's Name License # Phone j.f`3 T1-47 <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN '/? RECONDITION /_7 DESTRUCTION r7 � <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /? <br /> 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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS \A� <br /> Industrial - Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing ' <br /> Domestic/public. Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical. Surf ace Seal Installed By: .. � <br /> PUMP INSTALLATION: Contractor <br /> 4 R' <br /> Type of Pump H.P. <br /> F , <br /> PUMP REPLACEMENT; j_/ State Work Done <br /> PUMP .REPAIR: /77 State Work Done <br /> •pESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <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 <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 INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE .c <br /> (DRAW PLOT FLAN ON REVERSE SIDE <br /> DEPAJ&TMENT USE ONLY <br /> PHASE I PW <br /> APPLICATION ACCEP S AV EEL DATE ,�- Z 3-7� <br /> ADDITIONAL COMMEN <br /> PHASE IT OUT INSPECTION PHASE FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> Y E H 1426 Rev. 1-74 1-74 2M <br />