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V <br /> ""�v JOAQUIN LOCAL HEALTH DISTR2C'" <br /> FOT�.OFFICE USE: 16( s. Hazelton Ave. , Stockton, Ca- <br /> Telephone: (209) 466-6781 ~ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued L-22-;7_1- <br /> (Complete <br /> ,7_1-(Complete In Triplicate) <br /> Applica ion 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 Joaquil <br /> County Ordinance No. 1862 and the les and Regu ations of the San Joaquin Local Health District. <br /> JOB ADDRE OCATI ' � (,C -�-��% �[/ <br /> ON CENSUS TRACT <br /> Owner's / ��� I �l-� J/ <br /> Phone _ / <br /> Address / / ��L ��' � TY C���1\ <br /> _ Cit <br /> Contractor's Name License du/:� 395hone J-,�66 g6-r <br /> TYPE OF WORK (Check) : NEW WELL /-7 DEEPEN /-7 RECONDITION /-7 DESTRUCTION /- p <br /> PUMP INSTALLATION / / PUMP REUIR ,,.//F�—J PUMP LACEMENT /7 N <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 Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP '.REPAIR: / / State Work Done ✓ <br /> Y;—. - <br /> v , <br /> DESTRUCTION 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 ona _new well, -I_will furnish thy,ban Joaquin Local ealX - 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 INSP CTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED j�_�L, , J TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P S FINAL INSPECTION <br /> INSPECTION BY y DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 1. h7e 13*" <br />