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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR -OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 9 7 <br /> THIS. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date. Issued ��,Y ; <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 /> l5Sle .S'. auE � ,Zo.3O�f <br /> JOB ADDRESS/LOCATION Dy c. kyAd,__ ! , 0 '�2 � CENSUS TRACT <br /> Owner's Name — Phone 't3 7- <br /> V.V <br /> Address 2 City C is A/ r <br /> Contractor's Name „� License #. �, �/ Phone " <br /> V6A4 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/_/ RECONDITION / / DESTRUCTION /7 <br /> AL <br /> PUMP INSTLATION PUMP REPAIR /7-�- -PUMP REPLACEMENT /? <br /> Other /_7 <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 <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing (� <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel. Pack Depth of Grout Seal i <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical _ Surface Seal Installed By : <br /> PUMP INSTALLATION: Contractor <br /> € <br /> Type of Pump H.P. ' <br /> PUMP REPLACEMENT:— <br /> / / ='Done <br /> PUMP REPAIR:= /jam State Work Done <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,,tlie San Joaquin Local Health District <br /> and the State of Calkfornia pertaining to or regulating well "const.ruction. 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 othe well and notify�lfhem before putting the well in use.. The above <br /> information is true to th-e best of my.--knowledge 'and belief.' I WILL CALL FOR A GROUT INSPECTION 1 <br /> PRIOR TO GROUTIN2 AND A FINAL INSPECTION. ; � € <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I nn <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL' COMMENTS: ! <br /> PHASE II GROUT INSPECTION PHASE IV/FINAL IV/FINALINSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATES } <br /> 6/%7 <br /> E H 1426 Rev. , 1-74 <br />