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C 'ISAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF, OFFICE USE: X601 E. Hazelton Ave. , "Stockton, Calif. <br /> Telephone: (209) 466-6781 <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 Aereby 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 /> JOB ADDRESS/LOCATION J'vodl �n;-L 46 CENSUS TRACT '----- <br /> yS�cl <br /> Owner's Name P/ Phone ` 2 <br /> Address '. S} l T DS�u:; City QCe/ <br /> Contractor's Name C A / U l r License # ;17 , ;2 Phone V12-�.5 <br /> a <br /> TYPE OF WORK (Check) : NEW WELL Ar DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_7PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT j7 <br /> i Other. <br /> DISTANCE TO NEAREST: SEPTIC. TANK . _,SEWER ,LINES . .PIT. PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT /2 0� OTHER { r <br /> ! ,PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL � Lel <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 Casings /29 <br /> IrrigationGravel Pack-- Depth of GroutSe_al _ <br /> Cathodic Protection Rotary �. Type of Grout` <br /> Disposal Other Other Information <br /> Geophysical Surface�,Seal Installed By: <br /> PUMP INSTALLATION: 1 Contractor ' <br /> Type of Pump k H.P. <br /> PUMP REPLACEMENT: / / State Work Done . k <br /> PUMP .REPAIR: / / State Work Done <br /> 4 <br />� DESJRUCTION OF WELL: Well. Diameter kApproximate Depth^ <br /> Describe-'Mat,erial and Procedure A ' <br /> _ be <br /> I hereby agree to comply with-all laws-and-regulations of the San %Joaquin Local Health District <br /> and the State of California pertainingto or regulating well ''construction. _ Wlthin FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin� Local•,HealthADistrict a <br /> WELL DRILLERS REPORT of the well'afid' notify them before putting then well `in'-use. The,,above <br /> information is true to the best of my4knowledge and belief. I WILL-CAIL FOR A GROUT/INSPECTION <br /> ' PRIOR TO GROUTING AND A FINAL SPECTIO_ N. <br /> SIGNED ! TIT-LEI <br /> (DRAW PLOT PLAN ON REVERSE SIDE} <br /> y FORDEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II------------------------------ <br /> OUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BYDATE 'T INSPECTION BY { — DATE t'- ` <br /> 11771- 2H <br /> E H 1426 Rev. 1-74 <br />