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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB40FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone,: (209) 466-6781. � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S 3 ,trJ# <br /> .THIS PERMIT 'EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -2-5— <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. ' tt .(bfj •a CENSUS TRACT <br /> Owner r s Name ' s Phone <br /> Address. Y_ CIA <br /> . .� / .� City 's <br /> Contractors Name ) License * ��".;Z CPhone <br /> TYPE OF WORK (Check) : NEW WELL &-7 DEEPENL/? RECONDITION. /_7 /_7DESTRUCTION <br /> PUMP INSTAALATION / / PUMP REPAIR /-7 PUMP REPLACEMENTL7r <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC TANKC, I SEWER LINES PIT PRIVY <br /> ,. SEWAGE DISPOSE—FIELD CESSPOOL/SEEPAGE PIT OTHER Q � <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL� PUBLIC DOMESTIC -WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial . --_X Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia.nof Well'.Casing - <br /> . Domestic/public t Driven Gauge of Casing {; <br /> _ X Irrigation Gravel Pack Depth of Grout Seal i <br /> Cathodic Protection 'i Rotary Type of Grout , <br /> '„`Disposal. Other. Other <br /> Geophysical. <br /> —.---_-- - , <br /> Geophysical . y Surface Seal Installed BX: <br /> PUMP INSTALLATION:.- Contractor <br /> f; Type sof pump , H.P. <br /> PUMP REPLACEMENT: ' / / State''Work Done Y _ <br /> PUMP/,.REPAIR: State-Work"Doae`. <br /> f <br /> ESIRUCTION. OP' WELL: Well Diameter Approximate Depth <br /> !Describe-Material and Procedure <br /> hereby agree to comply witliall 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 <br /> PRIO& TO GROUTING AND A FINAL INSPECTION. INSPECTION. e <br /> SIGNED. i t. ,/ h TITLE , <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> 77 FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY . � DATE <br /> ADDITIONAL'. COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 7-74 1-74 2M <br />