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.. SAN JOAQUIN :LOCAL HEALTH DISTRICT <br /> 70TZFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: ,(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z.,��/35l° <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> 3�_ ~~^- (Complete In Triplicate) <br /> Applicatf6n is'hereby bade 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 o -m m&j CENSUS TRACT <br /> h <br /> Owner's Name [a ur ,Tv Phone <br /> Address 3 011 Ge' City zolvoikL <br /> r <br /> Contractor's Name pvaov ji5R4'e ff License ifs ?"'Phone 44� 04 <br /> i <br /> TYPE OF WORK (Check): i�NEW WELL/7 DEEPEN 1-T RECONDITION /_7 DESTRUCTION r <br /> ,PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT <br /> 'Other / / <br /> (�3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY p <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 p Cable Tool Dia. of Well Excavation <br /> Domestic/privatell, Drilled Dia. of Well Casing _d <br /> Domestic/public Driven Gauge of Casing <br /> 1 Irrigation ii Gravel Pack Depth of Grout Seal <br /> G Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information 7-d <br /> ' Geophysical. Surface Seal Installed B : <br /> y <br /> PUMP INSTALLATION: Contractor C <br /> Type of Pump H.P. <br /> h <br /> PUMP REPLACEMENT: ;� / / State Work Done <br /> PUMP .REPAIR: State Work' Done CdA2ke e ALSil-r <br /> I' ,PES;TRUCTION OF WELL: :i Well Diameter Approximate Depth <br /> f 1, 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 /> f after completion of my.hwork on a new well, I will furnish the San Joaquin Local Health District a <br /> I 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 n3 lief. I WILL CALL FOR A'GROUT INSPECTION <br /> PRIOR TO GRO T NG AND A FINAL INSPE CTIO <br /> SIGNED <br /> ; (D r LOT PLAN ON REVERSE SIDE <br /> OR DEPAATMENT USE ONLY <br /> " PHASE I L- �r <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: , <br /> PHASE II G OUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> j <br /> �� E H 1426 Rev. 1-74 _ - 1-74 2M _- <br />