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z SAN JOA UIN LOCAL �iEALTH DIST F <br /> FOFr;OFFICE USE: IOT yJ <br /> 1601 E E. Hazelton Ave Ave. , Stockton, Calif. NOFiGf�F;�D <br /> Tele-phone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit NoL <br /> THIS PERMIT EXPIRES 1 YEAR PROM DATE ISSUED Date Issud <br /> (Complete In Triplicate) 1f <br /> Application in hereby made to the San'Joaquin Local health District for a permit to canetruct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance N60, 1862 and the Ruled and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION , ZZaA, CENSUS TRACT I <br /> Owner's Name Phone <br /> Address S City , <br /> Contractor's Name _ J _._....._ _...., License # J��. ?� Phone L7S <br /> TYPE OF WORK (Check) . NEW WELL /7 DEEPEN '/? RECONDITION. /7 DESTRUCTION <br /> PUMP INSTALLATION ,/—/ PUMP REPAIR - PUMP REPLACEMENT /7 <br /> . .Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER j; + <br /> r PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELLJI <br /> INTENDED USE • TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial-- Cable Tool Dia. of Well Excavation II t`+ <br /> Domestic/private ' Drilled Dia. of Well. Casing Ij <br /> Domestic/public " Driven Gauge of Casing i. <br /> Irrigation . Gravel Pack- Depth .of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information : ' I; <br /> —Geophysics]. - Surface Seal. Installed B <br /> PUMP INSTALLATION: d <br /> Contractor <br /> Type .of Pump H.P. <br /> i <br /> ' d <br /> PUMP REPLACEMENT. - / / State Work Done I� <br /> PUMP-RE c ` ¢,17T_'-S-Cate Work Done <br /> li C <br /> f`,,-7. a ( -tet./ �5i` X7. 74" <br /> DESTRUCTION OF WELL: Well Diameter .---Approximate Depth J!' <br /> Describe Material and Procedure V <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 Healtti, District a <br /> WELL DRILLERS REPORT of the well and notify them before putting- the well in use.... The ,!above <br /> informatibn is true 'to. tb e-best-of my knowledge and belief. I WILL CALL FORA GROUT I' SPECTION <br /> PRIOR TO GROUTING ANDA FINAL INSPECTION.. <br /> SIGNED I' <br /> TITLE )21 <br /> (DRAW PLOT PLAN ON REVERSE SIDEr .— <br /> FOR DE ARTMENT USE ONLY ry <br /> PHASE I <br /> APPLICATION ACCEPTED-BX . DATE ,12 <br /> ADDITIONAL COMMENTS: <br /> _PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATEca <br /> E H�1G26 Rev. 1-74 r r 1.%�if au <br />