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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR',OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. fP <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3-1i "71. <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/LO ON � - CENSUS TRACT <br /> Owner's Name Phone C7 /~� ,-- <br /> Address f ` City')7CD <br /> Contractor's N ;;4--%)0- U et41ZDLicense < G6j6 ' <br /> # Phone <br /> TYPE OF WORK (Check.): NEW WELL /? DEEPEN /7 RECONDITION 17 DESTRUCTION /7 <br /> PUMP INSTALLATION L-_7 PUMP REPAIR ff PUMP REPLACEMENT /7 <br /> Other L7 <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 BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> .� <br /> PUMP REPLACEMENT: /-7 State Work Done r <br /> PUMP REPAIR: /7 State Work -,, % <br /> 07 <br /> ,PES®RUCTION 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 completion of my work on a new well, I will furnish the San Joaquin Local Health District is <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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED /YI n At- <br /> TITLE <br /> o� o S r , <br /> (DRAW PLOT PLAN ON REVERSE SIDE- �^ <br /> FOR DEPARTMENT USE ONLY .� <br /> PHASE I 571 <br /> APPLICATION ACCEPTED BY DATE -7 S <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br /> 1-74 2M <br />