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r[�' OFFICE USE; - ...t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , <br /> ,Stockton, Calif, <br /> Telephone: (209)' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) Date Issued <br /> Application is $ereby made fo the San Joaquin Local Health District for a permit to / <br /> and/or install the work herein described. This application is made in compliance <br /> an <br /> County Ordinance No. construct' <br /> 1862 aiid the Rules and Regulations of the San Joaquin Local Health with SDistrict. <br /> JOB ADDRESS/LOCATION 1:1�71 <br /> CENSUS TRACT ' <br /> Owner's Name Ca r <br /> G c%�` �_ Phone <br /> Address � .� <br /> Contractor's Name City ' <br /> � �;3 <br /> 4 TYPE OF WORK (Check) ; NEW WELLr <br /> DEEPEN / / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION /% PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TQ NEAREST; SEPTIC,TANK <br /> SEWAGE DTSPOSA LOWER LINES 5--B PIT PRIVY ' <br /> PROPERTY LINE •- PRIVATE DOMESTIC WECESSPOAL/SEEPAGE PI DOMESTIC INTENDED USE TYPE OF WELL MESTIC WELL- <br /> �_ Industrial CONSTRUCTION SPECIFICATIONS t <br /> domestic Cable Tool Dia. of We11 Excavation <br /> --�. /private Drilled Dia, of Well Casing f <br /> Domestic/public Driven <br /> _ Irrigation Gauge of Casing <br /> _ Gravel Pack <br /> Cathodic Depth of Grout Seal <br /> Protection -otary Type of Grout <br /> _Disposal 1 Other <br /> Geophysical Other Information <br /> S----------------- <br /> urface Seal Installed-B <br /> PUMP INSTALLATION: F <br /> Contractor <br /> Type ofjPump <br /> _ H.P. ' <br /> PUMP REPLACEMENT; State Work Done <br /> y S <br /> PUMP , # <br /> State Work Done <br /> S-TRUCTION OF WEL : 2z�� <br /> Well Diameter <br /> ''' Approximate Depth <br /> Describe10 terial an It Procedure <br /> S d <br />[ hereby agree to comply with all laws and regulations of he San Joaqu n Local alth District <br /> and the State of Calif.v_rnia,pertafning 'i�1'ati3n' -- �e'construction.,1oa <br /> Ifter completion of my work on a new well, ,I wi•1l ftirifgshettieSanJoaquinLocalhin FI TEEN,'D District a 4 <br /> � p-..y w. arra. <br />;ELL DRILLERS REPORT of the well and notify them before <br />.nformation is true to the best of m knowledge and belieftting the well in use. The above <br /> RIOR TO GROUTING AND y g I WILL CALL FORA GROUT INSPSCTTON <br /> NA INSPECTION. ' <br /> IIGNED <br /> TITLE F <br /> (DRAW PLOT PLAN ON REVERSE SIDE) •---". <br /> RASE I ` <br /> FOR DEPARTMENT USE ONLY <br /> PPLICATION ACCEPTED BY <br /> DDITIONAL COMMENTS: y DATE 7 <br /> PHASE II GROUT INSPECTIO <br /> NSPECTION BYDATE PHAS IT/F NAL INSPECTION <br /> j l INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 &Wyw- t A,7 �� <br />