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^^ �� SAN JOAQUIN LOCAL ,HEALTH DISTRICT <br /> FORiOFFICE USE: 1641 E. Hazelton.Ave. , Stockton, Calif. ' <br /> Telephone., (209) 466-67`81 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�L <br /> i <br /> THIS PERMIT EXPIRES 1SYEAR-FROM DATE ISSUED Date Issued <br /> ,.a(Complete In .,Triplicate) . <br /> Application is hereby made to the San Joaquin 'Local Health District for a permit to construct E <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 P s Name Phone CP- 7 <br /> Address. .. ;� <br /> city Esno <br /> Contractor's Namelr k <br /> A01rfi'�o _ - License # / Phone $ i 2 0 <br /> TYPE OF WORK (Check) NEW WELL /7 DEEPEN '/7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION_ /:FUMP_-REPAI___ R /� PTTMP 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 i Cable Tool Dia. of Well Excavation <br /> Dbmestic/private�4 Drilled Dia. of 'Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation i Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal . Other — _ Other Information ' <br /> Geophysical Sur--face Seal Installed BX: <br /> 1 <br /> PUMP INSTALLATION: FContractor..:�' <br /> .Type of Pump. R.P. <br /> PUMP REPLA <br /> CEMENT r'3�, �/ � State. Work Done .��'��? .���' •�.,���,. U <br /> PUMP :REPAIR: 7—* S <br /> �.ia j <br /> ES.TRUCTION OF WELL: Well Diameter i 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 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 P' A GROUT INSPECTION i <br /> PRIOR TO GROUTING D FIN INSPECTION: '� <br /> SIGNEDX'.AAPTITLE <br /> I <br /> . _(DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> A1'P ATION ACCEPTED BY� DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS. II NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - <br /> E H 1426 Rev. 1-74 -7A <br />