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i / <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE O�E L6 USE: \ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> �L• Telephone : (209) 466-6781 <br /> } I APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,-7 Qo.)0 <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 Joaquin , <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION � �� �/ I �(�}�� _ ri. U CENSUS TRACT { <br /> OwnerII's Name 2Phone <br /> - <br /> Address r.��rp City <br /> Contractor's NameF License # hone „[ <br /> . <br /> TYPE OF WORK (Check) : NEW WELL '/ / DEEPEN / / RECONDITION /_/ DESTRUCTION /-J <br /> PUMP INSTALLATION/ / PUMP REPAIR -Ig PUMP REPLACEMENT /_7 k <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> ty SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> E PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> ii' INTENDED USE I TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> IlIndustrial ;I Cable Tool Dia, of Well Excavation <br /> ,s Domestic/private 11 Drilled Dia. of Well Casing <br /> ! Domestic/public Driven Gauge of Casing - O <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> I Disposal 1 Other Other:- Information . <br /> 'i Geophysical ,; Surface Seal Installed By. <br /> PUMP INSTALLATION: Contractor / 4 <br /> Type of Pump r- H.P. <br /> PUMP REPLACEMENT: /.. /,. State Work Done <br /> PUMP .,REPAIR: State Work..Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I her 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 /> WELLDRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the-best of 10g(:�andbeief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR' TO GROUTING AMID A FINAL INSPE_WN <br /> y N. <br /> SIGNEDTLE <br /> IC W PLPLAN ON RE R E :SIDE} <br /> ' <br /> �EFOR DEPARTMENT USE ONLY j. <br /> PHASE Imo- 7 <br /> APPLICATION ACCEPTED BY11 DATE Z co,G <br /> ADDITIONAL COMMENTS: is !' <br /> ;E PHASE II GROUT INSPECTION PHASE III/,FINAL INSPECTION <br /> INSPECTION BY I' DATE INSPECTION BY DATE <br /> I� 11 3/76 2M <br /> E H 1426 Rev. 1-7411 <br />