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` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOh;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. .,6..3&4d <br /> 76 <br /> TIIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued <br /> ��.`{"�'�O _rtilx. .w.;�7�.t�S•�; <br /> (Com� <br /> v; plete In Triplicate) <br /> Application °is tzereb 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,Joaqu16 <br /> County Ordinance No. 1862 and the Rules and Regulations pf �the' San Joaquin Local Health District. <br /> of <br /> JOB ADDRESS/LOCATION L a J, o o 0 ' CENSUS TRACT <br /> Owner's Name Phone ' � 0 <br /> Address "-" A- J' O �( City , <br /> Contractor's Name ' License Phone <br /> TYPE OF WORK (Check) : NEW WELL. /�FPEN / CONDITION /-7 DESTRUCTION /'7 <br /> PUMP INSTALLATION_ PUMP REPAIR-/-7—PUMP REPLACEMENT /7 pp'' <br /> Other / I Wil" <br /> .DISTANCE TO NEAREST: SEPTIC TANKSEWER 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 <br /> ----�. ale Tool Dia. of Well Excavation -��' . �, <br /> mestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal I <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 a H.P. ---� <br /> - 4 <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP .REPAIR: /7 _State Work Done <br /> llE&TRUCTION 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 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 INSPECTION <br /> PRIOR TO GR NG AND A FINAL IWpEcTION. i <br /> SIGNED - TITLE Q <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 PHASE III FINAL INSFECTIO <br /> INSPECTION BY a DATE �� INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 qu r <br />