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i SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> v/ ,01 E. Hazelton" Ave. , Stockton, Calif. <br /> FOF4fOFFICE USE: <br /> ' iM Telephone: (209) 466-67$1 <br /> APPLICATIUN. FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 + 4L'7 <br /> d /1-1 7S <br /> Date Issue <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �--�=-� <br /> .k lk (Complete In Triplicate) for a permit <br /> Application is tiexeby made to the San Joaquin LocalHealthn istrict made in compliancef�lthnSan Joaqui.: <br /> and/or install the work herein described. This app <br /> 'County Ordinance No. 1862 and the Rules and Regulations of the 'San Joaquin Local Health District. <br /> � CENSUS TRACT - <br /> JOB ADDRESS/LOCATION <br /> kr ,J y; Phone <br /> Owner's Nam � e <br /> F /V <br /> '2 .. c_ Liv coe+! ] , d City 7a <br /> :Address <br /> License # _ Phone y <br /> Contr-actor's Name <br /> ,TYPE '19p WORK (Check}: NEW WELL/? DEEPEN/� RECONDITION /� DESTRUCTION <br /> PUMP INSTALLATION / 1 PUMP REPAIR /� PUMP REPLAC I�T <br /> Other / / <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ PIT PRIVY <br /> k h SEWAGE DISPOSAL FIELD <.570 °CESSPOOL/SEEPAGE PIT OTHER j <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> i9 Industrial Cable Tool Diaof Well Excavation <br /> A Domestic/private Drilled Dia.: of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> i� Irrigation Gravel Pack Depth of Grout Seal <br /> A Cathodic Protection Rotary Type of Grout <br /> + Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> V.... <br /> PUMP; INSTALLATION: Contractor <br /> F Type of Pump H.P. <br /> PUMP. REPLACEMENT: / / State Work Done <br /> PUMP. '.REPAIR: /_7 State Work Done L <br /> ,RES 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 <br /> ''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 <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 TITLE <br /> ;f DRAW PLOT PLAN ON REVERSE SIDE <br /> J. EPARTMENT USE ONLY <br /> PHASE I <br /> APPLIC��CEPTED �' Y -- _ TE <br /> ADDITIONAL. COMMENTS: �� *'. <br /> PHASE II GROUT INSPECTION. P ALNSPECTIO <br /> INSPECTION BY DATE INSPECTION. <br /> AT <br /> I. <br /> t E H 1426' Rev. 1-74 1-74 2M <br />