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1V- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F081'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S=/�) �94S) <br /> ]S= <br /> / x/& <br /> /a <br /> jTHIS 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 Ga �, - CENSUS TRACT <br /> Owners Name y Phone p i <br /> r <br /> Address -; - k <br /> City <br /> Contractor's Name , � � License # ! 4,:I?hone S <br /> TYPE OF WORK (Check): NEW WELL 'S { DEEPEN '/_7 RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT &r ' <br /> Other <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK >vO . 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 2F WELL CONSTRUCTION SPECIFICATIONS (J1 ' <br /> Industrial Cable Tool Dia, of Well Excavation 1 <br /> �s�, Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing /n <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection, Rotary Type of Grout •" 7-T)4 <br /> Disposal Other Other Information I <br /> Geophysical q <br /> - _. Surface Seal Installed Sy?,,,,,.,_... 1 <br /> PUMP INSTALLATION: Contractor _�_ k' <br /> Type of Pump H.P. <br /> _f .... <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP:!.REPAIR:- /-7- -Stiate�Woric Done <br /> ESMUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure ' <br /> 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 <br /> AYS -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 putting. the -well in-use.. The above p <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 /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE L-75 <br />` ADDITIONAL COMMENTS: rTOP <br /> PHASE II GROUT INSPECTIM PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE 7� s' INSPECTION BY DATE S y 7S <br /> f <br /> ,} E H 1426 Rev. 1-74 <br />