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.SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> .FOFr;OFFZCE -USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELT, CONSTRUCTION OR PUMP PERMIT Permit No. Z42 fo <br /> �6�93a p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued X76 <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/tOL4"RM <br /> CENSUS TRACT <br /> Owner's Name Phone <br /> I <br /> Address <br /> city ' . <br /> Contractor's Name /�cY �'� License � Ph 1 <br /> 7 one /® <br /> TYPE OF WORK (Check): NEW WELL;& DEEPEN '/? RECONDITION /_7 DESTRUCTION ./7 <br /> a F{: <br /> c._ <br /> PUMP INS ALLATION /'�/ PUMP REPAIR / /-:---PUMP REPLACEMENT /-]" ; <br /> - , <br /> Other, T` <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> PIT PRIVY <br /> SEWAGE DISPOSAL FIELD �-r— /SEEPAGE PIT , jgQ;f40THER = l <br /> t`PROPERTY_:LTWE�PRIVATE DOMPSTIC WELL/.�f PUBLIC DOMESTIC WELL---�— <br /> INTENDED USES � PE We WELL CONSTRUCTION SPECIFICATIONS z �\ <br /> Industrial Cable Tool Dia. of Well' Excavation ; ;. }} <br /> Domestic/private-, Drilled Dia. of Well Casing t ;. <br /> Domestic/public" Driven <br /> S Gauge of Casing <br /> � ., Irrigation I Gravel Pack- Depth of Grout Seal <br /> Cathodic Protectibn), Rotary Type o£ Grout _ <br /> Disposal �.. =- Other _ Other Information i <br /> Geophysical Surface Seal. Installed 'B <br /> PUMP`I'DISTALLATION: R Contractor . <br /> Type of Pump <br /> � H.P. <br /> PUMP REPLACEMENT: / / State Work Done k <br /> PUMP '.REPAIR: i <br /> /7 State° 1 <br /> Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with all lavas and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well `'construction. <br /> AYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local hHealth in �Diisstrict a <br /> WELL DRILLERS REPORT of the well and notify them beforeuttin .. the_weI eabove <br /> j <br /> information is true to the-best-of- my knowledge and belief. I WILL CALL FORA GROUT INSPECTION i <br /> PRIOR TO GROITTING AND A FINAL INSPECTION I <br /> SIGNED i <br /> ITLE S ! <br /> DRAW PLOT LAN ON REVERSE SIDE) <br /> PHASE I <br /> FDORPARTMENT USE ONLY <br /> APPLICATION' ACCEPTED BY DATE ' <br /> ADDITIONAL COMMNTS: <br /> PHA II G UT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - 2 <br /> E H 1426 Rev. 1-74 <br />