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SAN JOAQUIN LOCAL HEALTH DISTRICT . <br /> SCMNED <br /> FOR:OFFICE US-E-- 1601 E. Hazelton Ave. , Stockton Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 7/g <br /> t s <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued 3-3-7 <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 Joaquin <br /> County Ordinance No: 1862 and the Rules and Regulations of the San -Joaquin Local Health District. ; <br /> JOB ADDRESS/LOCATION <br /> c CENSUS TRACT Cdc1�� <br /> Owner's NameLQ X5 <br /> G` '�' Phone <br /> .Address , <br /> Ur City <br /> Contractor's Name License <br /> Phone <br /> TYPE OF WORKCheck): <br /> � NEW WELL/!KDEEPEN '/7 RECONDITIONL7 DESTRUCTION ;/_7 � <br /> PUMP INSTALLATION -/GYPUMP REPAIR '/? PUMP REPLACEMENT / f <br /> Other <br /> DISTANCE TO NEAREST: ' SEPTIC TANK SEWER LINES FIT PRIVY <br /> - SEWAGE DISPO AL FIELD CESSPOOLJSEEPAGE PIT - ; OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL" _PUBLIC_DOMBSTIC WELL k <br /> INTENDED USE TYPE OF WELL <br /> Industria-1TCONST1tUCTION SPECIFICATIONS -. k <br /> "_ Cable Tool. Dia. of Well Excavation <br /> Domestic ' �� <br /> /private -_- Drilled Dia. of Well Casing 17 <br /> Domestic/public. w� IDriven• Gaugeof Casing <br /> 1L Irrigationg <br /> * Gravel Pack Depth of Grout Seal ; <br /> Cathodic Protection Rotary € Type of Grout , <br />_______Disposal -�_ Other ¢ '+ Other Information <br /> Geophysical #, --�- <br /> Surface Seal Installed 'B : A71 <br /> PUMP INSTALLATION: <br /> . Contractor . 0 , <br /> Typ e. .o f Pump <br /> H.P. ' ID <br /> PUMP REPLACEMENT: , - <br /> . . / 4/ State Work Done <br /> PUMP .REPAIR: F <br /> /7 State Work Done <br /> 3ES-TRUCTION OF WELL: W611Diameter <br /> Describe Material and Procedure Approximate Depth <br /> C hereby agree to comply with all laws and regulations of the San Joaquin Local1Health District <br /> tnd the State of California pertaining to or regulating well •'construction. Within FIFTEEN DAYS <br /> tfter completion of my� work on a new well; I will furnish the .San Joaquin Local'.Health District a <br /> TELL DRILLERS REPORT of the well and notify them before Putting-the'-well in.use " .The above' <br />.nformatioil is true to the-.best-of- my.knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TO GROUTING AND INAL IN PE _ <br /> IGNED TITLE k <br /> DRAW PLOT PLANON REVERSE SIDE <br />'RASE I <br /> FOR DEPARTMENT USE ONLY <br /> � � � .r� ' _. t , <br /> PPLICATION ACCEPTED BY - <br /> DDITIONAL COMMENTS: DATE 31319 <br /> PHASE If <br /> NSPECTION BY GROUT. INSPECTION PHASE iII F AL INSPECTION <br /> •,�-DATE ,5-�:. INSPBCTIDN.BY�. _ :_ - <br /> E H 1426 Rev. 1-74 <br />