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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOP OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 6(3yo <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> ' 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 /> JOB ADDRESS/LOCATION fS aAa? <br /> CENSUS TRACT <br /> L Owner's Naive -_�A. Cr r S S: 0 _.., _._..,---.,....,— Phone <br /> Address / � � � t r <br /> I��_4E-.-.-0- 64tRd "Alf f_oAof __._._,.._,,.,__, City l7a1cO <br /> , <br /> }Contractor's Name 11 , veRfA4 4Cu License 46.&�W/ Phone ::g <br /> � y <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT 4ET <br /> Other <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 r �. <br /> I Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> F Domestic/public Driven Gauge of Casing- <br /> 1 <br /> asing1 k,—Irrigation Gravel Pack Depth of Grout Seal - <br /> Cathodic Protection Rotary Type of Grout '- <br /> Disposal Other Other Information <br /> Geophysical c' Surface Seal Installed`By: <br /> `PUMP INSTALLATION-. Contractor r A,-X[_ I?r4/. 0yn-4r _rLp QZ-i /--c <br /> Type of Pump u� b i. _♦ —H:P.- . Jam— <br /> ;PUMP REPLACEMENT: / / State Work Done ,�,yctl�' <br /> 'PUMP REPAIR: <br /> / / State Work Dane <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 /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED 4= TITLE <br /> z (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> 'ADDITIONAL COMMENTS: t <br /> ADDITIONAL <br /> r PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> .-INSPECTION BY DATE. INSPECTION BY DATE <br /> 2M <br /> E H 1426 Rev. 1-74 <br />