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low <br /> t SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: / 1601 E. Hazelton Ave. , Stockton, Calif. <br /> L ( Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,;;�-- � <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made o <br /> PP y t 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 /> j JOB ADDRESS/LOCATION {�/^(1 . ./(B /-�'o C�f, CENSUS TRACT - <br /> Owner's Name <br /> Phone <br /> Address 01 ZQ�: - LA A 65 /V e k City.9 SIC4141AI <br /> P 1 <br /> Contractor's Name ��r ��� = License Phoner� <br /> TYPE OF WORK (Check) : NEW WELL /DEEPEN / / RECONDITION /R, / DESTRUCTION <br /> PUMP�'INSTALLATION '/ / PUMP REPAIR'"-/ '/ '^-'PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: 'SEPTIC TANK " SEWER LINES PIT PRIVY <br /> SEWAGE DISP SO A�L FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELPUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i; Cable Tool Dia. of Well Excavation <br /> Domestic/privateDia. of Well Casings } <br /> Domesti /public * iven Gauge of Casing 7 4 <br /> ��Irrigation-e_- Gravel-PaFk Depth of Grout Seal ---- <br /> Cathodic Protection Rotary Type of Grout q <br /> Disposal Others, Other Information " <br /> j <br /> " Geophysical ,. <br /> Surf ace_Seal-'Installed B j <br /> �J INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / "State Work Done <br /> { <br /> PUMP .REPAIR: t /J-'.!'State Work Done <br /> DESTRUCTION 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 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 INSPECTION <br /> PRIOR TO G ING AND A FI INSPECTION, - <br /> SIGNED TITLE ✓f <br /> RAW Pig T' PLAN 'ON RE FRSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION '` PHASE II/FINAL INSPECTIQ.N <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 <br /> Rev. 1-74 <br />