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t ' <br /> F <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT OArOk'FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �S-o23�Zp <br /> THIS .PERMIT EXPIRES 1 YEAR FROM- DATE ISSUED <br /> ,.: Date Issued 4' <br /> (Complete In. Triplicate) <br /> Application is hereby made to.the San Joaquin Locai_Realth Diatrict for a permit to construct <br /> and/or install the work herein described. This application is made 4n compliance with San Joa uin <br /> I County Ordinance No. 1862' and the Rules and Regulations of the San Joaquin Local Health q <br />� h District. <br /> JOB ADDRESS/LOCATION . (�C/• � Ll%t'I y9., K <br /> CENSUS TRACT <br /> Owner's Name � T� j , LPJ Phone d- f�' ,� <br /> Address ��� -�-� �- L? /�-j�- � - <br /> City 7_1��� . <br /> Contractor's Name 2)� -)--T;eq <br /> U <br /> License #/Ca37]�Phone-IZ4 6 t76'7�`— <br /> TYPE OF WORK (Check): NEW WELL -/- DEEPEN '/? RECONDITIO /? DESTRUCTION /_7a y <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT /� <br /> Other /% �.. y <br /> DISTANCE I'0 NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 01 <br /> 1^J'� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT - <br /> OTHER 1� <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial. � Cable Tool Dia. of <br /> Domestic/private Well Excavation <br /> Drilled Dia. of Well Casing <br /> Domestic/public Driven F Gauge.of. Casing <br /> Irrigation Gravel, Pack Depth of Grout Seal. <br /> Cathodic Protection Rotary Type of Grout <br /> - <br /> Disposal Other Other Information <br />' Geophysical —�- . <br /> Surface Seal Installed By: <br /> F• <br /> PUMP INSTALLATION: Contractor 1 <br /> Type of Pump <br /> � H.P. <br />,TUMP REPLACEMENT: j/7 State Work Done <br /> PUMiP :REPAIR: _ state-Work Done es ` . <br /> ES`TRUCTION OF WELL: Well Diameter <br /> y Describe Materiand Procedure Approximate Depth <br /> al <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ;slid the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br />''after completion of any work on a new well, i will furnish the San Joaquin Local Health Disrfct a <br /> WELT, 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 TOGNU—TING AND A FINAL, INSPECTION. <br /> SIGNED <br /> �.: TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I ; "� 4 OR DEPARTMENT USE ONLY <br /> A PLICATION ACCEPTED BY ' <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II G I PE YON PMR FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION' BY <br /> µ . DATE <br /> E H 1426 Rev. 1-74 ' <br />