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SAN JOAQUIN LOCAL HEALTH DISTRICT lil <br /> FOA+OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. . I <br /> Telephone: (209) 466•-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7_5_41 <br /> �!��' THIS PERMIT EXPIRES 1 YEAR .FROM DATE ISSUED Date Issued`3_,./a 7$ <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 Joaquin : <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> LjAA <br /> JOB ADDRESS/LOCATI ��7 ; i.•��ff e1 CENSUS TRACT <br /> Owner's Name <br /> INUMUC <br /> Water Supply: public system 0 Community system ❑ Private,91 Depth,to Water Table ft. <br /> Hardpan ❑ �^ <br /> Contractor's Name — <br /> License #,a 5 777Phone zla�p-°� . <br /> TYPE OF WORK (Check): NEW :WELL _ DEEPEN/-7' RECONDITION /7 DESTRUCTION /7 <br /> f + PUMP INSTALLATION /� PUMP REPAIR /_7 PUMP REPLACEMENT E7 <br /> Other % / J <br /> DISTANCE TO NEAREST: SEPTIC TANK a SEWER LINES PIT PRIVY <br /> SEWAGE'DISPOSAL FIELD CESSPOOL SEEPAGE PIT/ OTHER 11 <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 ' 0 .f <br /> ' Domestic/private Drilled Dia. of Well Casing �� <br /> r ; <br /> Domestic/public Driven Gauge of Casing $ . <br /> ;•�.Irrigation _ __ 7/4Gravel Pack Depth of Grout Seal <br /> ,fi <br /> -_SZ _„ Cathodic Protection, otary Type of Grout <br /> _ Disposal ' Other Other Information <br /> Geophysical Surface Seal Installed- By: <br /> : <br /> x _ <br /> pL 7 INSTALLATION: Contractor <br /> Type of Pump - -H.P. & <br /> n 1+ <br /> PUMP REPLACEMENT: / / State Work Done <br /> �i <br /> PUMP :REPAIR: <br /> /_7 State Work Done <br /> E&TRUCTION OF WELL: Well Diameter Approximate Depth r � <br /> Describe Material and Procedure <br /> } <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Districti4" <br /> and the State of California pertaining to or regulating well construction. Within•FIFTEEN DAY <br /> dE.'� <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Distrid; <br /> WELL DRILLERS REPORT of the well and notify them before putting.the..well in-use.. The above- 4 <br /> information is true to the•best of- my knowledge and belief. I WILL CALL FOR A 'GROUT INSPgCTIOI__ <br /> PRIOR TO GRQUTINQ AND IN INSPECTION. . <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FO RTMENT USE ONLY <br /> PHASE I /J <br /> APPLICATION ACCEPTED BY QC, DATE <br /> ADDITIONAL COMMENTS: <br /> POiASE D GROUT INSPECTIO PHAU III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYj DATE <br /> E H 1426 <br /> ' Rev. I.-74 �' 7�! �/ X- /2M , <br />