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_ P ' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> -01i.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 6•Mylb <br /> THIS PERMIT EXPIRES 1 .YEAR FROM DATE 'ISSUED Date Issued <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 . /VCs�aJWJ•!"�L _ __ CENSUS TRACT <br /> Owner's NI Phone 36 g- I � <br /> ame <br /> p � <br /> Address 4 © lxet�A lam[ City ,- <br /> Contractor's <br /> ity ,-Contractor's Name License 7,3 Phone <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN/7 RECONDITION /_7 DESTRUCTION f_7 <br /> PUMP INSTALLATION /-/ -PUMP REPAIR —PUMP REPLACEMENT <br /> - :Other 1/7/ <br /> 1 <br /> DISTANCE TO NEAREST- .SEPTIC"TAMC-- -SEWER"LINES-'-.T-~`_`_PITT PRIVY <br /> SEWAGE.DISPOSAL-FIELD f CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE —PRIVATE DOMESTIC WELL` PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �! <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private A Drilled Dia. of Well Casing <br /> Domestic/public A Driven Gauge of Casing <br /> --Irrigation I Gravel Pack Depth of Grout Seal <br /> Cathodic Protection t Rotary Type of Grout <br /> Disposal i Other Other Information . <br /> Geophysical Surface Seal Installed 'B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ��n <br /> PUMP REPLACEMENT: . / / State Work Done <br />'t PUMP '.REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter _ - -_ Approximate Depth <br /> - - - - <br /> Describe Material and Procedure <br /> i 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 /> I -WELL DRILLERS RT of the well and notify them before putting. the.-well in-use,.. The above <br /> .information 19111trAe to the-bes .of my. know edge and belief. I WILL--CALL FOR A"GROUT INSPECTION <br /> PRIOR TO GROUAV <br /> A F SPECTIO <br /> SIGNED TITLE <br /> } DRAW PLOT PLAN ON REVERSE SIDE <br /> + <br /> FOR DEPARTMENT USE ONLY <br /> f `PHASE I -J <br /> APPLICATION ACCEPTED BYDATE ' S <br /> ADDITIONAL COMMENTS; <br /> ' PHASE II GROUT :INSPECTIONPHASE III FINAL INSPECT4N <br /> INSPECTION BY :DATE '-<' INSPECTION BY DATE ,7 l� <br /> V. u-,1G9{. »n., 7_71. { 1/75 2m <br />