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• I <br /> v. SAN JOAQUIN LOCAL, HEALTH DISTRICT <br /> FOE OFFICE USE: " 1601 E. Hazelton Ave., ,Stockton, Calif. <br /> Telephone: (209} 466-6781 j A <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES- I YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is Ikereby 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 Joaquini <br /> CountyOrdinance 1862 and the Rules and Regulations gulatians of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATI � � � --n--� CENSUS TRACT <br /> Owner's Name Phone i <br /> Address <br /> -}�=�C�. City <br /> Contractors Name .�.� �Q l <br /> {' ���--R� _, License #�� A�`Phone dna <br /> c _ _ s <br /> r c— <br /> � S - <br /> ti <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /7 RECONDITION /7 DESTRUCTION -7 <br /> PUMA' INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMBLff , 7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD- CESSPOOL/SEEPAGE-PIT OTHER " A <br /> PROPERTY LINE ='PEIVATK DOMESTIC:WELL PUBLIC..DOMESTIC ML— <br /> INTENDED <br /> L-INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation v <br /> Domestic/private ' Drilled Dia. of Well Casing <br /> Domestic/publicc; Driven Gauge of Casing <br /> Irrigation ti Gravel Pack Depth of Grout Seal } <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: , 4 <br /> PUMP INSTALIATION: Contractor <br /> Type of Pump H.P. / <br /> -PUHP SEPLACEl�IT: / / State Work Done %• °� '� X � <br /> PUMP -710AIR: / / State Work Done <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 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 G UTING AN FINAL INSPECTION. <br /> SIGNED TITLE --�51. „ <br /> } (DRAW PLOT PLAN ON REVERSE SIDS) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ' <br /> APPLICATION ACCEPTED BY DATE 4/-/ <br /> ADDITIONAL ,COMM:NTS: <br /> PHASE II GROUT INSPECTION P /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 9-27-72— <br />