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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO "OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit NobJa <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 4 2 97,.S,.j <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 CENSUS TRACT <br /> Owner's Name,/::/975 /Ofi!2 2V Phone <br /> 'Address / " - r' City <br /> License Jt5 > 23 PhonjA <br /> Contractor's Name <br /> "TYPE OF WORK (check) : NEW WELL /7 DEEPEN -/� RECONDITION /�� I]ESTRUCTION f7 , <br /> PUMP INSTALLATION / J PUMP REPAIR /`�C PUMP REPLACEMENT <br /> Other /-7 O } <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY Q <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL C <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation r , <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 /> r Type of Pump R.P. <br /> F <br /> PUMP REPLACEMENT: %/ State Work Done <br /> „ State Work Done <br /> r PUMP :REPAIR: <br /> ESTRUCTION 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 8 <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- myknowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED. TITLE 122 <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> 3 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P SE I I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE _ D�7 S <br /> t E H 1426 Rev. 1-74 ' / 1-74 2M . � <br />