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' F <br /> Co �.. � I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> I <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 /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> Cgt'�O '•"� j <br /> :�. . <br /> JOB ADDRESS/LOCATION ' p�o c.t��,�1 .�+�(j u.�x; � �� CENSUS TRACT [*5'~_ <br /> Owner°s Name -Lrm j,0-e Y/� Ott <br /> �c] Phone <br /> i <br /> Address .O. Aja City <br /> Contractor's Name •,� License Phone 6 <br /> TYPE•OF WORK (Check): NEW WELL -/_7 DEEPEN '/_7 RECONDITION /? DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELT. PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> - Industrial Cable Tool Dia. of Well Excavation 3 <br /> Domestic/private Drilled Dia. of Well Casing � <br /> Domestic/public- Driven Gauge of Casing <br /> Irrigation 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 � .'J 0d/. et � _ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /7 State Work Donewh�crrY�t]a+.o� <br /> A <br /> PUMP <br /> '.REPAIR:- /7 State Work Done '- <br /> E&TRUCTION 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 Rea'Ith District am, <br /> WELL'DRILLERS. REPORT of the well and notify them before putting..the .well in .use.. Tkie above <br /> information is true to the-best-of- my lea elief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TOgyg2ING, AND A FINAL INSPE - - ..----- <br /> SIGNED � LE � <br /> (D ' W PLOT PLAN :ON RE RSE SIDE <br /> FOR DEPPTMENT USE ONLY <br /> PHASE I --- <br /> APPLICATION ACCEPTED BY DATE -�• <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS INSPECT ON <br /> I INSPECTION BY DATE INSPECTION BY DATE - <br /> + ,E H 1426 Rev. 1-741=74 2M <br /> t - <br />