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x � SAN JOAQUIN LOCAL HEALTU DISTRICT <br /> FO$IrOFFICE USE: 1601 E. Hazelton Ave. ,_Stockton, Calif. <br /> Telephone: (209) 46£-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�e- � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued !j-2p-7� <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health Distirict 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 th.g-Rules and Regulations of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION % ;F. nu, © ��CENSUS TRACT z�-tlo a � <br /> Owner'S_Name / P �. Phone <br /> Address q' City llI <br /> Contractor's Name 5 -L r I License # 2fG j Phone Jr- j/ I <br /> / <br /> TYPE OF WORK (Check): NEW WELL /17r DEEPEN /? RECONDITION /7 DESTRUCTION %j � <br /> PUMP INSTALLATION PUMP REPAIR /_7 PUMP REPLACEMENT . <br /> Other /% <br /> i <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 ExcavationyL� <br /> Domestic/private Drilled Dia. of Well Casing <br /> E Domestic/public Driven Gauge of Casing <br /> Irrigation Z Gravel Pack Depth of Grout Seal -- <br /> Cathodic Protection � Rotary Type of Grout -- <br /> _______ Disposal. ' Other Other Information `QV) h4 j 6-tC2 ,Lj � <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP'. REPAIR.---- /_7 -State Work Done <br /> ES;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 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 FORA GROUT INSPECTION <br /> PRIOR TO ROUTING AND FINAI. SPE CT ION. <br /> SIGNED J TITLE Q <br /> ( W PLOT PLAN ON gRVERSE SIDE) l <br /> F0 nEPARTMEN USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE /Y— <br /> ADDITIONAL COMMENTS: <br /> I PHASE II GROUT INSPECTION ' PHASE 11I FINAL INSPECTION <br /> INSPECTION BYrI <br /> DATE INSPECTION BY DATE <br /> ~E H 1426 Rev. 1-74 <br /> 1-7 4 7M .. <br />