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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE,OFFICE USE: 3601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6.781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. f. 0- Lc1 <br /> THIS PERMIT-EXPIRES 1 YEAR FROM DATE ISSUED . sued I-- <br /> Date Is <br /> (Complete In Triplicate) 1c�3 - D to Issued <br /> Application is hereby .made to tore 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.. 1$62 and the Rules and ,Regulations of the Sane Joaquin Local Health District. <br /> JOB AD LESS/LOCATION W <br /> " J CENSUS TRACT 3 <br /> Owner's Name <br /> Phone <br />`Address �3 ;t <br /> 0-,t City <br /> Contractor's Names -32 1_s 3 i <br /> __ • - �;_t -,- - _ License __s-- _Phone_ <br /> TYPE OF WORK (Check): NEW WELL /-7/Z DEEPEN / / _ RECONDITION /? DESTRUCTION r7 — <br /> PUMP INSTALLATION IPl PUMP REPAIR / / PUMP REPLACEMENT ./7 <br /> - Other <br /> a. <br /> DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT BOTHER <br /> PROPERTYjLINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL r CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Dxillsd Dia. of Well Casing <br /> Domestic/public . Driven, Garage of Casing � p <br /> Irrigation , Gravel Pack Depth of Grout Seal So <br /> Caathodthod ic Protection kf.. Rotary Type of Grout _ <br /> Disposal - .f Other - <br /> Other Information, i <br /> Geophysical . _ Surface Seal- Installed__By., aGPk <br /> .. for lL <br /> PUMP INSTALLATION-. , Contractor f <br /> Typeof 4Pump H.P. <br /> "; r <br /> P[TMP.REPLACEMENT: s <br /> r /-/ tiState- Work-Done , <br /> - <br /> PUMP I.LEPEIIR: �-...��,...�." ..� <br /> !/ /-State Work Done <br />>ES•TRUCTION OF WELL: ,Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure t1. <br /> t Jtit y.1 <br /> C <br /> hereby. agree to acomply--withe ulations of the:San Joaquin Local Health District <br /> all laws and r8 <br /> end theVState of California pertaining to or regulating wel.l='rconstruction. Within FIFTEEN DAYS <br /> ifti r completion"of my work on a new well, I will furnish the San Joaquin Local Fealth District a <br /> BELL DRILLERS REPORT of the well and notify them before putting the..well in.use..f. The above <br />.nformation is true to the•best -of. my knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> RIOR TO GROUTING AND ,A`FINAL INSPECTION. 'k.. <br /> SIGNED TITLE <br /> c <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br />'RASE I <br /> FOR DEPARTMENT USE ONLY <br /> ,. . <br />-PPLICATION ACCEPTED BY - 7- DATE /- / -7(, <br /> DDITIONAL COMMENTS: <br /> PHASE .11 GROUT INSPECTION PRASE III FINAL INSPECTION <br /> NSPECTION BY T� DATE INSPECTION BY DATE / <br /> E H 1426 Rev. 1-74 <br />