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`'=r.:,. v►1 to� / r <br /> SAN JOAQUIN LOCAL-11EALTH DISTRICT —� <br /> FO10 'FiCE FTSE: 1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION rOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /b_7� <br /> Application is hereby made to the San(Joaquin Local Hlete In el 9_230--0 <br /> Health District for a permit to construct <br /> ?� <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/LO ATION t It <br /> CENSUS TRACT i <br /> Owner's Name ��^Q <br /> Phone <br /> Address �� , �,::�J O'� et' <br /> City I ®rte,D r�,• <br /> Contractor's Name <br /> License # Phone <br /> TYPE OF WORK (Check): NEW WELL /-" DEEPEN/7 <br /> / RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / PUMP REPAIR g/ PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LYNES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER � <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL .. PUBLIC DOMESTIC WELT, <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPE <br /> aon <br /> CTFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavti <br /> Domestic/private Drilled Q <br /> Domestic/public '— Driven Dia. of Well Casing 0 <br /> Ti Gauge of Casing <br /> ---� <br /> 'Irrigation Gravel Pack Depth of Grout Seal s (� <br /> Cathodic Protection Rotary T e of Grout - <br /> _ ,Disposal Other th <br /> i Geophysical —�,�� Other Information <br /> . - . t - Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump t <br /> PUMP REPLACEMENT: El- State Work Done <br /> 7 <br /> FZ]MP :REPAIR: State Work Done ./��w, / � <br />- ES TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply 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 work on a new well, I 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 <br /> information is true to the-best "of-'my kn wledge a d belief. i WILL CALL FOR AGROUT INSPECT <br /> PRIOR UTING D A FIN SPE IO ION <br /> SIGNED <br /> ` «tksE <br /> TITLE ` <br /> W PLOT LAN ON SIDE i <br /> PHASE`I FOR DEPARTMENT USE ONLY k <br /> APPLICATION ACCEPTED BY . DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE INSFECT ON <br /> IT FINAL T <br /> INSPECTION BY DATE INSPECTION .By <br /> - -- DATE x <br /> E H -1426 Rev. 1-74 <br />