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oc <br /> __ 5AN JOAQUIN LOCAL HEALTH DISTRICT r <br /> FOE-OFFICE 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 he/eby made to the San Joaquin Local "Health Distract for a permit -to construct <br /> and/or install th/e work herein described. This application is made in compliance with San Joaquin <br /> County OrdinanQ_ _ <br /> lN1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRE .�lOQi� S/ate 60 Al ZF L".C'e CENSUS TRACT <br /> Owner's NG �Q Phone z7d <br /> Address j �r <br /> Son Joaquin rump Co. city <br /> Contractor's Name (Division of San Joaquin Suip,u- e;.) License #37 <br /> Phone � / <br /> acre i. <br /> a <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /-7- <br /> PUMP INSTALLATION / W,:�;7VUMP REPAIR / / 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 1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation Q <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 By: <br /> PUMP INSTALLATION: ContractorSilFd Jca Err 9a <br /> Type of Pump <br /> C-1 e, H.P. ' /Q <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> DES-TRUCTION OF WELL: Well Diameter y 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 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 <br /> information is true to the best of my knowled e and belief. I WILL CAL FO A GROUT INS ECTION <br /> PRIOR TO GRO D A FIN L INSPE TI <br /> SIGNED (jt TITLE (Division of San Joaquin Suiphur Co.) <br /> (DRAW PLOT PLAN ON REVERSE SIDE) 71}-T" I° - <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE - �"�--N" <br /> ADDITIONAL COMMENTS: <br /> PHASE II G INSPECTION PH4SE I I/ 'NAI. INSPECTION <br /> INSPECTION BY _ DATE INSPECTION BY DATE 2. <br /> E H 1426 Rev- 1-74 7.-711 0/77 <br />