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JOAQUIN LOCAL H ALTII DIS.,PI:C'I,, <br /> FOR OFFICE, USE: jj// 160 . Hazelton Ave. , ,.Stockton, Cal <br /> Telephones (209) 466-6781 <br /> APPLICATION FOR WELL"CONSTRUCTION OR I%'W 'PERMIT Permit No. ,7i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7-/7- 7�1 <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 andRegulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION >> 7 ` - 1,J GCENSUS TRACT <br /> Owner v s Name _ _ r 6$_111_ -_r_4.a a_y o ri", Phone <br /> Address �� $ aj k-.; v. C-" a City <br /> Contractor'-s' Name F` P License # y.—Phone <br /> TYPE OF WORK (Check) :',! NEW WELL /� DEEPEN /_7 RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP;.REPAIR / PUMP REPLACEMENT /? <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 Drilled ., Dia. of Well 'Casing <br /> Domestic/public' Driven Gauge of Casing <br /> Irrigation Gravel Pack `*Depth of Grout° Seal <br /> Cathodic Protection Rotary 4Type of Grout <br />�:. Disposal Other Other Information <br /> Geophysical `.;Surface Seal. Installed By:_ _ <br /> : <br /> PUMP INSTALLATION: Contractor = , <br /> Type of Pump H.P. 7 ►.� <br /> PUMP REPLACEMENT: / / State Work Done <br /> 4 PUMP '.REPAIR: / / State Work Done <br /> DES-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 <br /> Califfo nia pertaining to :or regulating well construction. Within FIFTEEN DAYS <br /> after completion of m`y work on a new well . 1 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 NSPE.CTI 4: t <br /> TITLE <br /> h '(DRAW PLO PLAN ON VERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> i. PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II, GROUT INSPECTION PHASE III/ TINAL INSPECTION <br /> INSPECTION BY DATE - BYINSPECTION DATE <br /> E H 1426 Rev. .1-74 <br />