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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> "Ge -USE: ' 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 ` <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. :z•7 .5' ,3&') <br /> 9made <br /> THIS' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date ,Issued(Complete In Triplicate) <br /> Application is bier to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application ia.made in. compliance with San Joaquin] <br /> County Ordinance "No 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION _ _ "_ . ENSUS TRACT :203-l !ta " <br /> _ - <br /> Owner's Nameo Phone Q 7 <br /> Address s, ` <br /> City <br /> Contractor's -NameWe ILD cl\ L hq TzoL License. Phone a <br /> F Check) ; <br /> NEW WELL DEEPEN <br /> �..a_ /�%y RECONDITION / / DEST <br /> TYPE OWORK { RUCTION /7a . � <br /> PUMP INSTALLATION;/ / PUMP REPAIR / / PUMP REPLACEMENT '17 {{ <br /> Other / / — -� # t <br /> DISTANCE TO NEAREST: SEPTIC TANK _SEWER LINES Z PITrPRIVY- ..4 .. <br /> SEWAGE*DISPOSAL.-FIELD - - ss^ CESSPOOL/SEEPAGE P _TT "" OTHER ` <br /> PROPERTY LINES-' PRIVATE DOMESTIC WELL/-2.0-1 PUBLIC DOMESTIC WELL <br /> INTENDED USE ' TY'PE OF;WELL- � CONSTRUCTION SPECIFICATIONS <br /> Industrialr-- Cable ,Tool _ Dia. of Well Excavation <br /> D,omes,tic/prx'vate Drilled Dia, of We11 Casing v. r <br /> Domestic/publics Driven Gauge of Casing . <br /> Irrigation � - <br /> X $ 6;f -Gravel Pack' Depth of Grout Seal <br /> _,_,�.,_ Cathodic P.ro.tection f Rotary. ; , - Type of Grout . 3 <br /> a <br /> Disposal ,- <br /> Other Other Informations- tNJ <br /> Geophysical - Surface Seal Installed By: j <br /> PUMP INSTALLATION: Contractor , <br /> Type of Pump H.P. b, r <br /> s <br /> PUMP REP,,LACEMENT: / / State Work Done ` <br /> PUMP REPAIR:4 `� ' ,/ / State Work Done ._ <br /> DES•TRUCTiO'NIbF [BELL: Well DiameterApproximate Depth e <br /> Describe Material and Procedure <br /> I kereby agree to comply with all laws aiid� e,gulations 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 the wel and notify them before putting the well in .use. The above <br /> information true to the bes of y kn,w dge and belief. I WILL CALL FOR A GROUT INSPECTION . <br /> PRIOR T RO AND FINAL S TI <br /> SIGNED _ TITLE <br /> u <br /> (D W PLOT ,PLAN ON REVERSE SIDE) r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION-ACCEPTED BY. __.. ,.� --DATE <br /> ADDITIONAL COMMENTS; .gip <br /> PHASE II-'GROUT-INSPECTION - - PHASE I/FINAL INSPECTION. <br /> INSPECTION BY DATE IN ECTION BY DATE-4 <br /> E H 1426 - Rev. 1-74 l !�8 / �77:� -2M <br />