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SAN JOAQUIN LOCAL HEALTH DISTRICT- <br /> . —E USE' 1601 E. Hazelton Ave. , Stockton, Calif'. <br /> FOF� <br /> OFFICE Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;7./:,- 7l 7 <br /> THIS PERMIT EXPIRES. 1 YEAR FROM DATE ISSUED <br /> Date Issued <br /> In Triplicate)(Complete p <br /> Application ie hereby made to the San JoaquinLocal <br /> Health <br /> e listrict made ir�rcomplianicetwith San Joaquiny <br />` -and/or install the-work herein described. Th pplication <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> I CENSUS TRACT <br /> SOB ADDRESS/LOCATION <br /> Phone <br /> ,owner's Name <br /> Name <br /> / City <br /> Address q'`g <br /> License # Photid L2- GL <br /> Contractor's NameNDITON <br /> -7 DESI <br /> TYPE OF WORK (Check) : NEW ,WELL:._h'DEEPEN '/-p[1�[P REPAIRI/_/PUMP REPLACIEMENYrT <br /> pUMPT INSTALLATION <br /> Other 1-7 k� . <br /> PIT PRIVY .� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES OTHER <br /> SEWAGE DISPOSAL FIELD CESSPOOL/.SEEPAGE PIT <br /> S PUBLIC DOMESTIC WELL <br /> PROPERTY LINE - PRIVATE DOME5TIC WELL CONSTRi1CTI0N SPECIFICATIONS <br /> i INTENDED USE TYPE OF WELL -�� e <br /> I Industrial r _ Cable•,Tool. Dia. of Well Excavation 6 <br /> Domestic/private Drilled Dia. of Well Casing C <br /> Driven. Gauge of Casing <br /> Domestic/public' <br /> omestic/public Gravel Pack Depth of Grout Seal <br /> ' E Irrigation <br /> Type of Grout <br /> i Cathodic Protection Rotary p her Information <br /> Disposal0the5 <br /> R <br /> ���- Surf ace Seal Installed BY: <br /> Geophysical <br /> PUMP INSTALLATION: "Contract orH <br /> ' - C <br /> .P. � <br /> Type of Pump <br /> � <br /> PUMP REPLACEMENT.�. + _State Work Done <br /> t // <br /> PUMP !REPAIR: / ; -State Work Done <br /> iApproximate Depth <br /> ES;TRUCTION OF WELL: Well Diameter. ==z � <br /> i Describe Material and Procedure <br /> istrict <br /> I hereby agree to comply with ail laws and regulns owelleSan Joaquin construction.LoWithin.;IFTEMC DAYS <br /> and the State of California pertaining to or regulating <br /> I after completion of my wojk on a new well, I will furnish the San <br /> Joaquin Local Health District <br /> i 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 TING AND A FIN INSPECTION. TITLE "A <br /> 1 5IGNED (DRAW PLOT PLAN ON REVERSE SIDE <br /> Ia <br /> FOR DEPARTMENT USE ONLY -� <br /> PHASE I .� r `.'' DATE - <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: ► {: . �- PHASE III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY DATE /a INSPECTION- BY DATE �'Q ' '7 <br /> 1_7.4 .2M <br /> 't _E H 1426 Rev. 1-74 - <br />