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C <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0TZFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7-!;-- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the Sett Joaquin Local Health District for a permit to construct <br /> I and/or install the work herein described. This application is made in compliance with San Joaquir <br /> County Ordinance No. 186 and the Rules and Regulations of the San Joaquin Local Health District.. <br /> JOB AD :- ' <br /> )kESS/L�CATTON CMCJ -� CENSUS TRACT <br /> Owner's Name Phone J <br /> Address G-c� .sf, ��Z City <br /> Contractor'sNameQ �-�!�i PCS License � honeTX-_�, � <br /> TYPE OF WORK (Check) : NEW WELL/_7 DEEPEN -/-7 RECONDITION 1-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION/ / PUMP REPAIR -/77—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 USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <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 . Other Information " <br /> Geophysical Surface Seal Installed 'B : ry <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - H.P. <br /> PUMP REPLACEMENT C7 State Work Done <br /> PUMP REPAIR: :State Work Donn'/_ l4-U f <br />' DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> F I 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 /> t 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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> 40':� <br /> FOR PARTMENT USE ONLY <br /> PHASE I <br /> AP. ILP�C.ATION' ACCEPTED BY o DATE, <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION' PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 ( h//75 2M <br />