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SAN JOAQUIN LOCAL HEALTH DISTRICT 4� <br /> OR•jOFFICE USE: 1601 E. Hazelton Ave. ,- Stockton, Calif. <br /> Telephone: (209) 466-6781 _P <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7G-FAI <br /> :f J6-sem <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �:, Date Issued //-/,2--,� <br /> (Complete In Triplicate) <br /> Application is hereby made tolthe San Joaquin Local-aalth District for a permit"to construct <br />. and/or install thie. icork herein described. This application is made in compliance with San Joaquin <br /> County Ordinance .N6. 1862 and the Rules and Regulations of the San Joaquin Local Health District. ; <br /> a.�i <br /> JOB ADDRESS/LOCATION �.�' . - A0 elfar, f' __.. __. CENSUS TRACT <br /> Owner's Name 7 A �1'4 � f Phone <br /> Address _ ,0 city , 4 <br /> Contractor's `Nme � License # Phone„?!jr / <br /> TYPE OF WORK (Check): NEW WELL /R�' ^DEEPEN -/_7 RECONDITION /—T DESTRUCTION f7 4 <br /> PUMP INSTALLATION /Z7'7PUMP REPAIR' /—/ PUMP REPLAcEmENT /? <br /> Other <br /> DISTANCE TO NEAREST:: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL'-FIELD `l. 'CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC" WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial rj Cable ,Tool Dia. of Well Excavation \ <br /> �L, Domestic/private A Drilled Dia. of Well Casing_ v� <br /> y <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation i Gravel Pack Depth of Grout Seal <br /> Cathodic Protection t Rotary Type of Grout !f3g:Z:!_ <br /> Disposal i Other Other Information <br /> Geophysical Surface Seal Installed By: '4e-- <br /> PUMP INSTALLATION: Contractor <br /> +' Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done i <br /> PUMP 'REPAIR: <br /> /_7 State Work Done <br /> R S-TRUCTION OF WELL: Well. Diameter Approximate Depth <br /> Describe Material and Procedure \�n <br /> I hereby agree to comply withiall. laws and regulations of the San Joaquin Local Health District Vl� <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYSyy <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a k <br /> 'WELL. DRILLERS REPORT of the well and notify thea 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 <br /> i (DRAW PLOT PLAN ON REVERSE SIDE) -FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P III FIN IN ECTI <br /> INSPECTION BY DATE INSPECTION BY DATE /v <br /> E H 1426 Rev. 1-74 l-74 2M <br />