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` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOH PFFICIE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR'WELL CONSTRUCTION OR PUMP PERMIT Permit No.7-7 9M; <br /> C THISI-PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued I d� 7 <br /> (Complete In Triplicate) <br /> Application islhereby made to 'the San Joaquin Local Health District for a permit to construct <br /> and/or install the work hereinldescribed. This application is made in compliance with San Joaquin EE <br /> County Ordinance No. 1862 and �the Rules and Regulations �of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name y- Phone <br /> . p <br /> Address /��. City d <br /> Contractor's Name } " License # Phone <br /> s <br /> TYPE OF WORK (Check) : NEW WELL/ EEPEN RECONDITION / / DESTRUCTION /-7 <br /> W' <br /> PUMP.:_..INST-AI,LATION -/ /AZPUMP--REI'A-IR-1�-lPUMP"�'REPL-AM'FMN-T-'�7-7'-4— � <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> -SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY I.T-NE4-. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL � <br /> INTENDED USE TYPE OF ELL CONSTRUCTION SPECIFICATIONS <br /> dustrial Cable Tool Dia. of Well Excavation l 2_Z/' <br /> Domestic/private. , D Drilled Dla of Well Casing' . r, <br /> Dome.stic r ' <br /> /public �Drivez� Gauge of-Casi,.ng <br /> Irrigation , Gravel Pack _ Depth of Grout Seal e9 <br /> r.Cathodic Protection ' Rotary Type of Grout <br /> Disposal y� � Other;,; 0the r�In-fermati-on <br /> Geophysical Surface Seal Installed_ B_y: <br /> PUMP INSTALLATION: Contractor <br /> Type of 'Pump t H.P. r <br /> ti <br /> PUMP REPLACEMENT,: /7 State Work Done + <br /> PUMP .REPAIR: ._._ <br /> / / State Work Done <br />)ES4RUCTION OF LLt " 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 /> TELL DRILLERS REPORT of the well and notify them before putting thewell in use.. The above <br /> information is true-,,to the best of -my_.:knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO GROU ING' AND FINAL INSPECTION. <br /> 3IGNED1 TITLE <br /> I (DRAW PLOT PLAN ON REVERSE SIDE) s <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I' <br /> APPLICATION ACCEPTED BY DATE !Z tl <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> k <br /> E H 1426 Rev.. 1-74 ' 11Z7 2M r <br />