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SAN JOAQUIN LOCAL HEALTH DISTRICT �5 <br /> FOF OFFICE USE: 1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone : (209) 466-6781 ,7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No_ q1-/1-t:-,/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate)' <br /> Application is hereb ode 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 S—L ,l, /) SUS TRACT <br /> ' u <br /> Owner's Name � , ,.�'� .41 +�� �i�47 K �l'T (L, Phone <br /> Address /R"10 -1� �-/ V City r <br /> mow. - <br /> Contractor's Name �, „t,� ��� ,� License �ca�-7�0� Phone 01 <br /> r <br /> TYPE OF .WORK (Check) ,"NEW..WELL / / DEEPEN / / RECONDITION /_/ DESTRUCTION <br /> PUMP .INS.TALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> r <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES _ PIT PRIV <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAt;E'PIT OTHER <br /> y PROPERTY LINE - PRIVATE DOMESTIC WELL ___ ' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> f Industrial Cable Tool Dia:,jof Well,Excavation <br /> Domestic/private Drilled Dia-:-a off Well, Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout 'Seal <br /> Cathodic Protection Rotary Type Of! Grout_, 11% <br /> Disposal Other Other Information <br /> Geophysical Surface, Seal Installed By : <br /> PUMP INSTALLATION: Contractor S i� <br /> Type:.of Pump F}/ti H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP .REPAIR: / / State Work Done v <br /> DESTRUCTION 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 /> j information is true to the best of my knowledge and belief. I WILL CAL OR A. ROUT INSPECTION <br /> PRIOR TO GROU G AND A FIN . INSPECTION. <br /> SIGNED TITLE _ <br /> . (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ,.tet <br /> APPLICATION ACCEPTED BY i6� .c 1 •�! ' - -- ----— DATE 1%� 3 `77 <br /> k- ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIOP III/FINIII/FIN4 INSPECTION <br /> INSPECTION BY DATE INSPECTION BY W WE 1 I '-7-7 <br /> E H 1426 Rev. , 1-74 <br /> 2M <br />