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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOA OFFICE USE: Y 1601 E. Hazelton Ave. , Stockton, Calif. '07,,l _17141 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76,776i�j <br /> y <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued L, -a?9 7� <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 Joaqui <br /> ,ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ��� L� !// u� J�2� !��' CENSUS TRACT <br /> —Amer's Name , mac,c i� 7� , Phone 7��5- �//C <br /> f!i �.�� /� <br /> lddress ��� 7�--4i�z�� U�� City cY�•-ems , <br /> Contractor's Name License # 74,P Z- Phone yL1--J-5i <br /> TYPE OF WORK (Check) : NEW WELL /°, DEEPEN /7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR F7 PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY <br /> OSAL FIE <br /> SEWAGE DISPLD CESSPOOL/SEEPAGE PIT OTHER C <br /> _ PROPERTY LINE - PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS F <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing j <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: gyp` <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump A.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMPtREPAIR: /7 State Work Done f <br /> ES•TRUCTION 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 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 IF4N=All INSPECTION. <br /> SIGNED f f y TITLE <br /> `. (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> `APPLICATION ACCEPTED BY .fes L' DATE /19 <br /> ADDITIONAL COMMENTS: i /j6 fir roPo .xUJ�YV!/ �L3�GZ C/v_AA�y_g• <br /> PHASE II GROUT INSPECTION t7 PI&SE III/eFINALvINSPECTION <br /> INSPECTION BY DATE //- •,7,/� INSPECTION BY j DATE =; 7 <br />