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I SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: U 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No�� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued/P/, <br /> (Complete In Triplicate) <br /> Application is hereby made t� the San Joaquin 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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> I � <br /> JOB ADDRESS/LOCATION fr <br /> /� CENSUS TRACT <br /> Owner's Namer I& �/ G✓�//,r�'G '�/-- - ' <br /> S. _ -'1 Phone - 4 :a <br /> Address' ' City <br /> Contractor's Name fJC. License g27 Phone , . <br /> TYPE OF WORK (Check) , NEW WELL DEEPEN /_% RECONDITION /7 DESTRUCTION /j <br /> PUMP INSTALLATION � PUMP :REPAIR I I 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 USETYPE OF WELL"`kF z - .j 9 '. I CONSTRUCTION SPECIFICATIONS f <br /> IndustrialCable Tool Dia df W ' <br /> � ell Excavation <br /> Domestic/private ' �` Drilled °+ Dia.•af Well Casing v <br /> Domestic/public Drivenauge sof Casing _1 ,.c, <br /> Irrigation Gravel Pack Depth hof Grout Seal - r � <br /> Cathodic Protection Rotary Type of Grout s <br /> I Disposal Other -OtherInformation <br /> Geophysical Surface Seal Inst 'alled. By: �e <br /> PUMP INSTALLATION: Contractor <br /> `f <br /> Type of Pump P 6 H.P. <br /> PUMP REPLACEMENT: <br /> / / State Work Done <br /> PUMP_..REPAIR:, _ _/ / State Work Done, <br /> DESTRUCTION OF WELL: Well iameter 1 I �1 Approximate depth a <br /> - ; -A - "NDescribelMaterial and Procedure 1 6 <br /> I hereby agree to comply- with all laws and regulations, of the San Joaquin.Local HealthjDistrict <br /> and the..Statetio€ California pertaining4to or regulating weil ',constructi6iit Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local HealthtDistrict a <br /> WELL DRILLERS REPORT of the well and notify themibefore putting the -well ;k�A <br /> Thelabove <br /> information is true to the-best of my..knowledge andbelief. I .WILL CALL GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL' INSPECTION. <br /> SIGNED TITLE- - <br /> W P T" PLAN RE ERSE SIDE '' <br /> ' FOR DEPARTMENT USE ONL'"Y.—" ' <br /> PHASE I Y � <br /> APPLICATION ACCEPTED `1 DATE - <br /> ADDITIONAL COMMENTS: <br /> P E II rQROUT INSPECTIO PHA / NAL INSPECTION S <br /> INSPECTION BY DATE S INSPECTION BY ATE ; <br /> 3/76 2M <br /> EH 1426 . Rev. 1-74. 1?-1?. � �!. � ., , v <br />