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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR F ICER USE: 1601 E. Hazelton. Ave. , Stockton, Calif. <br /> Teleph94e : (20,9) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 711.�L <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 E' E/yt ,ep,� 7 CENSUS TRACT <br /> Owner's Name (� %fel Phone <br /> Address 4/1[ City A� 4 <br /> Contractor's Name lv � [ }License 1956�g�iione 3 2 <br />'TYPEsOF IORKY"(CYieck)`:"NET,i�W�LI / DEEPEN /_% Rk0ONTION /_/ DESTRUCTION <br /> DI <br /> PUMP INST LATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> - � <br /> _ ter <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWERJLINES � P T PJRIVY <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 /> --Industria-17— CaBle Topic 1 - Dia,.of,We II Exc�-,avation f` <br /> X Domestic/private Drilled l .J 4� D 1 a"- of-W _ <br /> e11 Casing <br /> Domestic/public Driven t G Gauge of Casingiy ` /�. <br /> Irrigation Gravel P ck t��pth of Grout Seal ' E-- J �"�7 <br /> Cathodic Protection Rotary Type of 1. <br /> Disposal Other Other il'liormatidn- <br /> Geophysi call t. —Surf-aee---�eal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump .� ` y ` H.P. . <br /> PUMP REPLACEMENT: / / State Work Done' } <br /> PUMP REPAIR: / / State Work Done . - <br /> DESTRUCTION OF .WELL: ~ Well Diameter Approximate Depth (���' <br /> Vt ( Describe Material aria Procedure <br /> I hereby agree to comply with all laws aridregulations of the SR Joa rn L . al Health District <br /> and the State of California pertaining to or regulating well "constr-uction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, fI 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 f <br /> information is true to the best of. my knowle'd'ge and•-belief.I"WIL17* CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU LNG AND A FINAL INSPEOTION, <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I G <br /> APPLICATION ACCEPTED BY DATE ,42 t <br /> ADDITIONAL COMMENTS: _ <br /> PHASE II GROUT INSPECTION PHASE III/FINAL, INSPECTION <br /> INSPECTION BY­__2Z DATE 7� , ��� INSPECTION BY DATE wf <br />`i E H 1426 Rev. , 1--74 <br />