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j C? a - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOA!OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> . a <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 worXIherein described. This application is made in compliance with San Joaquin <br /> County Ordnance No. 182 and the <br /> Rules and Regula ons of the San JSWquin Lo al alth District, <br /> i <br /> JOB ADDRESS/LOCAW§N <br /> CENSUS TRACT <br /> Owner's Name= /� / Phone D 3 Jr 3 <br /> Addressoee,7, -8 [ .� ` ✓ -�-� �,,� City <br /> Contractor,!s Name � 7' 4p '_f License hone <br /> TYPE OF WORK (Check).* N4W WELL -L-7 DEEPEN -/-7 RECONDITION /7` DESTRUCTION <br /> PUMP INSTALLATION / j PUMP REPAIR 1_7PUMP REPLACEMET <br /> N <br /> p Cher <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT i OTHER <br /> P$OPERTY LINE - PRIVATE <br /> 1. . :. <br /> DOMESTIC WELL `PUBLIC DOMESTIC WELL �_l`! <br /> INTENDED USE TYPE OF WELL '' CONSTRUCTION SPECIFICATIONS <br /> „ Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private i, Drilled -Dia., qf Well Casing <br /> Domestic/public Driven Gauge' of Casing 1 <br /> Irrigation Gravel Pack DepW of Grout Seal <br /> Cathodic Protection Rotary TYPeNof Grout-A <br /> Disposal Other Other Informatilon <br /> Geophysical /77 Surface�Seal Installed B <br /> li. <br /> PUMP INSTALLATION: Contractor <br /> hype of Pump - - / t H.P. :. <br /> '1L � <br /> PUMP REPLACEMENT: j / State WorkDo��'� <br /> PUMP_:REPAIR:r__, _ ; /TT,State LWork'Done r <br /> ESTRUCTION 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 '4e 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 GROUTING ANDA FINAL INSPECTION. <br /> SIGNED TITLE <br /> �h DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - <br /> APP�A TON, ACCEPTED BY f DATE <br /> ADDITIONAL ,.COMMENTS <br /> PHASE II GROU INSPECTION PHASE IIIF NAL IN <br /> INSPECTION BY V DATE INSPECTION BYDATE - 2 l 7 <br /> 1 E H 1426 Rev. 1-74 1-74 2 <br />