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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. <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/Lo1:t <br /> � / 2 9 F - cENsus TRACT <br /> a <br /> Owner's Name -C.L'-aU Phone. 3 -a a,:z <br /> or <br /> Address (1-94 r1 city , <br /> Contractor's Name p License Phone ,� 4o_ I _ <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/ / RECONDITION /_/ DESTRUCTION /_7AL } <br /> PUMP INSTLATION PUMP REPAIR PUMP REPLACEMENT /7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT P�IVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ' . <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well. Excavation � t : <br /> t Domestic/private Drilled Dia. of Well Casing <br /> - Domestic/public. Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grou6 Seal ` <br /> Cathodic Protection Rotary Type of Grout ``- <br /> -Disposal, Other Other Information <br /> Geophysical Surface Seal Ii stalled By: <br /> \�-) <br /> PUMP INSTALLATION: , Contractor i <br /> T3�peF'of_P_ump�� <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work Done. P i <br /> �. 5 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Des �-be Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the SaiWoaquin Local Health District <br /> and the State of California .pertaining to or regulating well "contruction. Within FIFTEEN DAYS G <br /> after completion of my wort �6n a new well, I will furnish the Sa• ,oaquin Local Health District a , <br /> WELL DRILLERS REPORT of th ;teil and notify them before putting he'well in use. The above ; <br /> information is tie to the e t of my knowledge and belief. I W :LL° CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT D A F N INSPECTION. <br /> SIGNED TITL <br /> D W PTS T PLAN ON RE FRSE SDE <br /> FOR DEPARTMENT USE ONLY + <br /> PHASE I I <br /> APPLICATION ACCEPTED BY DATE 2z_zaz'_')6/ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION r` PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY e . DATE is t <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 .. , <br />