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G� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO£�:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone:, (209) 06-6781 <br /> APPLICATION FOR WEL=D-CONSTRUCTION OR PUMP PERMIT Permit No. <br />' THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete 1n Triplicate) 06S 070, Zf <br /> Application is hereby made tci_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 /> i County Ordinance No. 1862 and the Rules and Regulations of the San -Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 3 G�r++��. CAN TRACT <br /> I Owner's Name `Phone ' <br /> Address / 0 1 9 <br /> City <br /> r <br /> Contractor's Name License # , 'hone GJ <br /> t. <br /> TYPE OF WORK (Check) : NEW WELL '/_-7, '-DEE /? RECONDITION /7 DESTRUCTION r7 <br /> PUMP INSTALLATION /_/ PUMP REPATR PUMP REPLACEMENT /7 -� <br /> .PUMP <br /> DISTANCE TO 'NEAREST.-.,,,, SEPTIC--TANK { SEWER LINES PIT PRIVY ' ^0 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE r PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE „ -TYPE. OF. WELLj q CONSTRUCTION SPECIFICATIONS, <br /> Industrial ` A''"f Cable Tool Dia. of Well Excavation m <br /> Domestic/privat'e Drilled i Dia. of Well Casing <br /> Domestic/public Driven f Gauge of Casing a <br /> t, <br /> Irrigation Gravel Pack Depth of Grout Seal I I <br /> Cathodic Protection Rotary Type of Grout 1 I <br /> Disposal Other Other Information <br /> Geophysical a .-, Su face Seal Installed 'B 3 <br /> PUMP INSTALLATION: Contractor VZ.! s` 1� <br /> Type of Pump H.P.: , <br /> { <br /> t PUMP REPLACEMENT: State Work Donee �{ <br /> PUMP REPAIR:__ State Work Done �(r� <br /> � w <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> r <br /> V .0 <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District , <br /> and the State of ornia pertaining to or regulating well "-construction. Within FIPTEEN DAYS <br /> after completi of my work on a new well will furnish the San Joaquin Local Health District a <br /> WELL DRILLER REPORT the well a d no f them before putting..'the.-well.=in use..... The above <br /> informati.o is tr a he st w ge and belief. TWILL!CAUL 'ORA RDU L_INSPECTION- <br /> PRIOR TO G OU' - `PI �- _ � <br /> SIGNED` =sem', �TITLE z ' <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I a <br /> APPLICATION ACCEPTED BY DATE — k- A( <br /> ADDITIONAL COMMENTS: �{ <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> -+.--- - <br /> _ E H 1426 Rev. 1-74 h/75 7 2M <br />