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�Z N JOAQ UIN LOCAL HEALTH DISTRICT 1 <br /> FOw;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 -,/j /O � <br /> THIS PERMIT EXPIRES 1 YEAR• FRON 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 he Rules ajd.2pgulatioqs of the San -Joaquin Local Health District. <br /> JOB ADDRESS/LOC CENSUS TRACT 2-2t <br /> Owner's Name Phone ' <br /> ,sl,7"7 77--A <br /> Address City <br /> Contractor's Na License 13 4hone4/'9G <br /> TYPE OF WORK (Check): NEW WELL/ / DEEPEN '/-! RECONDITIO /J DESTRUCTION f_ <br /> PUMP INSTALLATION / I PUMP REPAIPUMP REPLACEMENT I? <br /> R/ / i <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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private " z Drilled Dia.� of Well. Casing �r <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 B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done00 <br /> , <br /> PUMP 'REPAIR: / / State Work Done <br /> IE . <br /> DES- <br /> TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> L . <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.knowledge and belief. I WILL CALL FOR A ,GROUT INSPECTION <br />' PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED �.�, - �,,� 3 _ TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> f PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION SE I F N SP_ECTIPN <br /> INSPECTION BY DATE INSPECTION BY A <br /> r{� r <br /> 1 V a ILIA � n , 9/. !9 1��r_- ��..i.�v/n.�,�n:ta�����l"�����'�"��`C�:' C�'�'riR`'^�' � h l7 7 .2M <br />