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SAN JOAQUIN LOCAL HEALTH DISTRICT !sS- <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. ; Stockton, Calif. t <br /> Telephone : (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /b-x-77 <br /> (Complete In Triplicate) i <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 Joaquin <br /> County Ordinance No. 1862 and the Rules <br /> and Rcrur la�tioCnseveof �e San Joaquin JoJoaaqu"in OLocal <br /> �H5eal�th/�D�iys4trG1iGc, <br /> t. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name Phone <br /> Address <br /> City S7'ur.C'�,,,. <br /> Contractor's Name 1 A j2 4ap License Phone 'z <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /_/ DESTRUCTION /7 _ <br /> PUMP' INSTALLATION / / PUMP REPAIR REPLACEMENT <br /> Other <br /> DISTANCE TO -.NEAREST.:.,,,SEPTIC 'TANK SEWER LINES PIT PRIVY <br /> x SEWAGE DISPOSAL FIELDCESSPOOL/SEEPAGE PIT OTHER <br /> ' PROPERTY LINE -- PRIVATE -DOMESTIC WELL PUBLTC -DOMESTIC-WELL <br /> INTENDED USE � - TYPE OF WELL CONSTRUCTION SPECIFICATIONS Q <br /> Industrial'• f 4 Cable Tool Dia. of Well Excavation O; <br /> r��' r <br /> Domestic/private Drilled Dia. .of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary ' Type of Grout <br /> Disposal Other r Other Information• <br /> Geophysical Surface Seal Installed By: f <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - - H.P, ' <br /> PUMP REPLACEMENT: / / State Work Done it <br /> PUMP REPAIR: / State Work Donea me 4. <br /> Y-- <br />)ESTRUCTION OF WELL: Well Diameter Approximate Depth k <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the. San Joaquin- L-oca-1 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 Sart Joaquin Local Health--District <br /> WELL DRILLERS REPORT of the well and notify them before putting thewell in use. . The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTI <br />'RIOR TO GROUTING AND A FINAL_ INSPECTION. <br /> SIGNED <br /> _ TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br />?RASE I <br /> APPLICATION ACCEPTED BYDATEQ- J72 <br /> WDITIONAL COMMENTS: <br /> PHASE II GROUT. INSPECTION Y _ �SE. TTI/;FINAL. INSPECTION <br /> INSPECTION BY, DATE . INSPECTION-..BY; � ; � _ -. DATE <br /> -.��� <br /> 4 <br /> E -H-1-426 Rev- 1-74 0!77 ! wM <br />