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SAN JOAQUIN LOCAL HEALTH DISTRICT -G L Dttjr� <br /> F UOFFICE USE: .1601 E. Hazelton Ave. , Stockton, Calif. �/ X �b <br /> " Telephone: (209) 466-6781 �O <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit NoZ__Y1:A_SV <br /> y THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued/-,�D_,. <br /> (Complete In Triplicate) <br /> i 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 /> AA,, ZS-11 60CLHO � <br /> JOB ADDRESS/LOCATIONItl_AL . LQ h Vmfyj 1> CENSUS TRACT <br /> Owner's Name Phone l <br /> 1 Address /0),3 P,-2 J 1z z1 t ve City10iO <br /> Contractor's Name It. a , License # Phone m <br /> TYPE OF WORK (Check) : NEW WELL jj DEEPEN %/ RECONDITION /_/ DESTRUCTION j? <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /? <br /> I <br /> Other '/ / <br /> DISTANCE TO NEAREST: SEPTIC TANK Ik 0 j. SEWER LINES PTT PRIVY _ <br /> SEWAGE`DISPOSAL FIELD ;00 4 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 19 <br /> Domestic/private Drilled Dia. of Well Casing 5 ":a — <br /> Domestic/public Driven ' Gauge of Casing / r'C <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 B i <br /> PUMP INSTALLATION: Contractor -� <br /> Type of Pump H.P. <br /> F - <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP­REPAIRs /�/`:-S•tate-Work Done - <br /> k DESTRUCTION OF WELL: Well Diameter ; 0 Approximate Depth <br /> Describe Material and Procedure <br /> I I::hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> f and the State of California pertaining to- or regulating well'construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, l 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 /> informaton is trueOthe best of my-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO ROUTING 'AN FINAL INSPECTION. <br /> SIGNED t TITLE <br /> E DRAW- PVDT PLAN `ON REVERSE- -SIDE_,- <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ` DATE JAZ - 30 ?� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIO PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE y-/'I��� <br /> I <br /> E H 1426 Rev. 1-74 � ! GJ ' �.,aGr G�� ;; <br />