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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO rOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. k <br /> ,Telephone: (209) 466-6781 <br /> APPLICATION�FOR WELL CONSTRUCTION OR PUMP PERMIT-•-- - ,, Permit No.�S <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED -Date Issued ,.p&-7,f i <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 /> County Ordinance No. 1862.,and the Rules and Regulations of the San Joaquin Local Health District_. I <br /> 1 a 7- f rwQ3 U30B �ADDRESS/LOCATION A-+h.h /✓ CENSUS TRACT <br /> V <br /> Owner's Name �it� L b u-✓ Phone <br /> Address O <br /> City rYi )e <br /> 3 <br /> License # LS Bone ]-"ie:7 <br /> Contractor'a Name a3-7--l- i-1-hone <br /> TYPE OF WORK (Check): � NEW WELL /7 DEEPEN /� RECONDITION /_7 DESTRUCTION � ry� <br /> PLT AL <br /> INSTLATION / / PUMP REPAIR /X/ PUMP REPLACEMENT j `,► <br /> k Other <br /> DISTANCE TO NEAREST: SEPTIC .TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT . OTHER <br /> PROPERTY LINE - 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 /> Domesticjpublic Driven Gauge of Casing <br /> — hrigation `:,, - Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other--Information <br /> Geophysical surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ✓. d H.P. f> <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP-.REPAIR: State Work Done > Q <br /> I <br /> j3ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> k� 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 regul.at.ing 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 besty kno edge nd bell f. I WILL CALL FOR,A GROUT INSPECTION <br /> PRIOR UTING AND A FINAL N E I <br /> SIGNED ITLE <br /> �+ W--PLUT PLAN ON RSE SID2. - s <br /> r- FOR DEPARTMENT USE ONLLYPHASE I <br /> }�, <br /> I APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PRASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> w <br /> 1 '4 E H 1426 Rev. 1774 1-74 2M <br />