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SAN JOAQUIN LOCAL HEALTH DISTRICT �. <br /> FOFsrOFFICE USE: 1607. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone; (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.'7S5 <br /> 4 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to 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 Joaqufn <br /> County dinance No 1862 and the„Rules and Regulations of the San Joaquin Local Health District. ` <br /> JOB ADDRESS/LOCATION ��j _Z3o. <br /> CENSUS TRACT � <br /> Owner°s Name , /moi-e-r„��,� Phone 7 22 3 G <br /> Address (� (0 a w F <br /> �� city <br /> . <br /> Contractor's Name License #/_ �3 13 Phone= <br /> r <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN '/? RECONDITION /_7 DESTRUCTION _� <br /> PUMP INSTALLATION / / PUMP REPAIR ��PUMp REPLACEMENT /� <br /> Cather /% � <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 DOMESTTC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable. Tool _._ _Dia. of Well Excavation <br /> ,.Domestic/priyate.; _. `A Drilled Dia" of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotar <br /> Disposal �' Type of Grout <br /> Other _ Other Information <br /> Geophysical - Surface Seal. Installed By: � <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: F7 StateWork Done <br /> PUMP-REPAIR:- State-Work Done <br /> E&TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure r Approximate Depth <br /> T 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 the well and notify them before puttingthe.-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 GROU G 1&wD A EIM INSPE ION. <br /> SIGNED TITLE <br /> (DRAW PL %LAN,ON REVERSE SIDEPHASE I F DETMENT USE ONLY * <br /> APPLICATIONiACCEPTED BY > �- <br /> ADDITIONAL' .COMMENTS: DATE <br /> PHASE II GROU INSPECTION r <br /> INSPECTION BY PHASE IIT FINAL INSPECTION <br /> DATE INSPECTION BY E DATE /--/�,l-�2G <br /> TE H 1426 Rev. 1-74 <br />