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E �!� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 209: <br /> Tele hone466-6781 <br /> P � ) <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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 work herein described. This application is made in compliance with San Joaquin <br /> r County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION q75'000 6 F CAV x412 'A.� CENSUS TRACT <br /> Owner's Name Phone �(— 7 -- <br /> Address- SA"i City <br /> i Contractor's Name S r,� r}s�.� License #,RZ3d1O Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/—/ RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /_ <br /> .Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES9 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD .r CESSPOOL/SEEPAGE PIT OTHER <br /> - PROPERTYIIINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE , TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial-, '""-� 'Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing fir, <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> t Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information_ e <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor -� <br /> Type of Pump -- H.P. <br /> PUMP REPLACEMENT: /_7 State'W,ork•Done <br /> PUMP .REPAIR: State Work Done .,' Aon <br /> DES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply 4ith all laws and regulations—of the--San-Joaquin--Loc-ai Health- District <br /> ` and the State of California' pertainning to or regulating well•construction. Within FIFTEEN DAYS <br /> G after completion of my work on a new *ell, "Twill furnish the San Joaquin Local Heaith .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 TOG UT NG OD.A FINAL INSPECTION. '- f <br /> SIGNED &&ZeTITLE ` <br /> 11, <br /> (b <br /> RAW Pt T- PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPWTION PHAS.H?III/ZTNA INSPECTIO <br /> E INSPECTION BY DATE INSPECTION BY ' <br /> } DATE <br /> �E H. 1426 Rev. 1-74 <br /> 3/76 2M <br />