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- 17� SAN JOAQUIN LOCAL -HEALTH DISTRICT <br /> ' FOR,OFFICE USE: 1601 E. Hazel'tori.Ave-.., ',Stockton, Calif. <br /> Telephone: °.:(209) 46.6=-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1- YEAR- FROM DATE ISSUED Date Issued - S <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquiu, 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 ani the...Rules and-=Regulations-of the San Joaquin Local Health District. <br /> JOB ADDRESS./LOCATION <br /> CENSUS TRACT <br /> Owner c s Name w c7'cr.r�r _(,� r - - Phone 36 © t <br /> � � A <br /> �e y �9 <br /> Address �is'r1IPS 11 .�nf. Cit _� fr1T <br /> Contractor's Name. l License # Phone <br /> �-._--�,_., �� � =4— - � <br /> TYPE OF WORK (Check): NEW WELL // DEEPEN. /_� RECONDITION -pump <br /> PUMP INSTALLATION � PUMP REPAIR /7 - PUMP REPLACEMENT /_T <br /> Other'E/_ <br /> // <br /> DISTANCE TO NEAREST: SEPTIC' TANK =0 SEWER LINES d P PIT PRIVY L <br /> SEWAG21DISPOSAL FIELD C SSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL . PUBLIC DOMESTIC WELL Q <br /> INTENDED USE tTYPE OF WELL CONSTRUCTION SPECIFICATIONS 'SVR <br /> Industrial Cable Tool Dia. of Well Excavation A <br /> —� Domestic/private `1 Drilled Dia. of Well Casing <br /> Domestic/public A Driven Gauge of. Casing � <br /> Irrigation Gravel, Pack '_ Depth.of Grout Seal <br /> ..Cathodic Protection Rotary '; ' Type of Grout _i&A' -- <br /> Disposal Other Other Information <br /> Geophysical 'Surface -Seal Installed By: <br /> PUMP INSTALLATION: Contractor _`�•c% <br /> . . . Type.'of Pump <br /> H.P. <br /> LPUMP REPLACEMENT: / / ;,State Work Done <br /> PUMP 'REPAIR:=_ - / ,�:,State_Work Done - <br /> ES:iRUCTION OF WELL: Well [Diameter Approximate Depth <br /> � Describe Material and Procedure <br /> �O <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 theiwell 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 /> TITLE O <br /> SIGNED "G <br /> 67Z1 (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY -- <br /> ADDI,TIONAL COMMENTS 1. <br /> PHASE 11 GROUT- INSPEC ION PHASE_III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 't <br /> 1-74 2M <br /> xE H 1426 Rev. 1-74 <br />