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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOEL _FTICE USE: 1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> -.7APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z6=22-1310 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued / 7 <br /> (Complete In Triplicate) <br /> Application is hereby de to `the San Joaquin Local Health District for <br /> a permit to construct <br /> and/or install the work herein described. This application is made in -compliarice with •Sau Joaquin <br /> County Ordinance No. 18'62 'and the Rules and Regulations' of the-' San Joaquin Local Health District. <br /> i 3 3� . .. G�._.�.,,..�-r..��: �� . . .. �,» CJ+(1-112--0.3 <br /> /�J <br /> JOB ADDRESS/LOCATION R p ` p .9 ' CENSUS 'TRACT <br /> k <br /> Owner's Name ' 2 yfJA SCS Phone /D <br /> (� y S �. 5 T C jt 7'o-*' 57- City G <br /> Address . <br /> Contractor's Name Son Joaquin Pump Co. License # / "7�'Phone l <br /> k <br /> I'(Division of San Joaquin WPM Col <br /> 40 <br /> TYPE OF WORK (Check) : INEW 17VEE 1�fa �' / / RECONDITION / / DESTRUCTION /� J <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 /> o' PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> [ INTENDED USE 11 TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> { . <br /> Industrial s Cable Tool Dia. of Well Excavation W <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 /> ` <br /> PUMP INSTALLATION: Contractor. <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: �i /Lr= State.Work Done Oij !/ <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 DRILLERSmREPORT o€ 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. FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND ISA FINAL INSPECTION. Son Joaquin Pump CO. <br /> SIGNED ..0 TITLE , <br /> � all <br /> W'P T PLAN an <br /> ON RE FRSE SIDE) <br /> OR DEPARTMENT USE ONLY ";, Califarnia 95240: <br /> F PHASE I <br /> APPLICATION ACCEPTED BY DATE f �$17� <br /> ADDITIONAL COMMENTS: i�� , <br /> L PHASE II":,GROUT INSPECTION - PHASE- III/' FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E J74' 3/76 2M <br /> E H 1426 Rev. .1 <br />