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SAN JOAQUIN LOCAL HEALTH DISTRICT AfLk G <br /> FOBiOFFICE USE: 1601 E. Hazelton Ave. Stockton, Calif. <br /> Telephone: ' (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT' Permit <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued 19-3- q- <br /> (Complete In Triplicate) - 1-0-7 tela--o( <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 Joaquit <br /> County Ordinance No. 1862 and. the Rules and Regulations o e San Joaquin Ifocal He <br /> lth District. <br /> JOB ADDRESS/LOCATION SPC-.?O-.?0 / C U1 ,6 eoc <br /> jZaWr1?L>CENSUS TRACT <br /> i' Owner's Name A/74_P ZE <br /> Phone 416 - y�Z <br /> Address 4 f - Ta <br /> 12 ze� City <br /> E: Contractor's NameC LAI?* L <br /> License # Phone 97 <br /> TYPE.OF WORK Check. :. . .NEW _ <br /> ( ) WELL-�DEEPEN -/_-7—RECONDITION- /77-4DESTRUCTION-",E- <br /> PUMP INSTALLATION / / PUMP REPAIR /-7—pump REPLACEMENT %T <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES PIT_PRIVY <br /> k SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER o <br /> PROPERTY 'LINE PRIVATE DOMESTIC WELL' . ' `PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS i m <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, <br /> Cathodic Protection RotaryType of,Grout ; ~� <br /> i Disposal •. Other Other Information , <br /> Geophysical _ Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor a <br /> Type of Pump H.P. <br /> r.. <br /> Pte' REPLACEMENT: / / StateWork Done <br /> PUMP 'REPAIR: /-7 State Work Done <br /> 1 <br /> ES. ZUCTION OF WELL: Well Diameter Approximate Depth <br /> - Describe Material and Procedure <br /> ,i I hereby agree to d ply with --all laws,and;regulations of the San Joaquin Local health District <br /> ' and the State of California pertaining-to'-or`regulating well construction. , Within FIFTEEN DAYS <br /> after completion of my workona new well, I will furnish the San_Joaquin=Local.-Health District a <br /> WELL DRILLERS}REPORT of the well and notify thea: before putting the. well. in.use.. The above <br /> information is trueF,to the beet.-of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO fVROTJTING AND=>kYINAL INSPECTION. <br /> SIGNED —��` , , TITLE _ <br /> V`^ �.! (DRAW PLOT PLAN ON REVERSE SID � <br /> R DEPARTMENT USE ONLY <br /> PHASE_ I �3 <br /> APPLICATION ACCEPTE BY, DATE Z. Z2 <br /> ADDITf01VAL 1COMMENTS: , <br /> v <br /> .PHASE II GROUT INSPECTION PRASE III FINAL INSPECTION . <br /> INSPECTION,$Y L- DATE INSPECTION BY DATE <br /> i. <br /> E H 1426 Rev. 1--74 1-74 2M <br />