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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209,) 466-6781 G <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7d-S�7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued / :1-71 <br />� ,. (Complete In Triplicate) <br /> Application is hereby ma �"de 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 -ana the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION a 46 <br /> • <br /> - CENSUS TRACT ' <br /> Owner's Name �j Phone <br />` Address ._ / city <br /> fOf, <br /> Contractorts Name 5 LicenseZd0 Phone 1 (j <br /> i c <br /> i <br /> TYPE OF WORK (Check) : NEW WELL _X DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_ <br /> AL _ <br /> 4 PUMP INSTLATION /�Q PUMP REPAIR / / PUMP REPLACEMENT <br /> y"�` <br /> Other 1/7 — — <br /> DISTANCE TO NEAREST: SEPTIC ITANK /190Y-SEWER LINES r PIT PRIVY �— <br /> '�� SEWAGE ;DISPOSAL FIELD CESSPOOL/SEEPAGE PIT �Q 74-GTHER <br /> PROPERT,YTLINE A�PRIVATE DOMESTIC WELL -- PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS . <br /> Industria] X Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation i 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 /> Vows <br /> Type of%-;P i ' H.P. <br /> PUMP REPLACEMENT: / / State ,Work Done �_ N <br /> PUMP .REPAIR: .'. <br /> State Wo-r-k Done <br /> IDESTRUCTION OF,WELL: . Well Diameter` ' Approximate Depth <br /> e, , 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_we11, I_wz11 furnish_the_San�Joaquin_Local_Health_District a <br /> WELL DRILLERS REPO_RT 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 F R A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL. INSPECTI 2 <br /> "Ts <br /> SIGNED t <br /> ! -" (DRAW PTOT KANPTO ON REVERSE- SIDE)- <br /> FOR gPARTMENT USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED BY _ <br /> ADDITIONAL COMMENTS:� <br /> PHASE I GROUT INSPEC N n PHASE II FINAL. INSPE 0 <br /> INSPECTION BY C �' DATE y NSPECTION BY C DAT <br /> b 2M <br /> E H 4 -6� Rev- 1-74 <br />