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-"� SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone.• (209) ' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit N0,�yL-- =ill , <br /> THIS 'PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued l��742 7 <br /> (Complete In Triplicate) ------7 <br /> Application' is Verebiy made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work hereinjdescribed. 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 CENSUS TRACT . <br /> Owner's Name `kj 1 Phone <br /> Address �� �; ���- ! City C <br /> Contractor's Name <br /> License #& 322Phane_S-fsVf <br /> •� i <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN17 RECONDITION /_7 DESTRUCTION /-7PUMP INST LATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other /I/ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOS FIELD .,_�-d I CESSPOOL/SEEPAGE PIT o � OTHER (, <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL j <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS _ <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private i Drilled Dia. of Well Casing S C <br /> Domestic/public - t Driven Gauge of Casing <br /> Irrigation 1 Gravel Pack Depth of Grout Seal _ <br /> Cathodic Protection - Rotary Type of Grout _•.•_. ^T <br /> Disposal F Other Other Information <br /> Geophysical Surface Seal Installed By: ( �/> <br /> PUMP INSTALLATION: Contractor � e <br /> Type ofPump /Y1 S/ H.P. _ <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: We1Z 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 completi.on?of my work onfa new well, I will furnish the San Joaquin Local Health District a R� <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 myknowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO GROUTI A FINAL INSPECTION, <br /> SIGNED _ TITLEP <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> I FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED Br-'/ <br /> DATE,_5, (f� % <br /> ADDITIONAL COMMENTS: � ¢ <br /> PHASE II GROUT INSPECTION�• F /FINAL INSPECTION did <br /> INSPECTION BY �, DATE 3`= Co- 77� INSFF,CTION�.BY DATE <br /> .E H 1426 Rev. 1--74 ., ,• .r#f - fl7 �"„�' <br />