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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. D A I <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.-18-62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> a2ujta:�991. <br /> ENSUS TRACT 0/3- 2-ze--0/ <br /> 1 .. o. <br />' Owner's Name y Phone <br />� Address .. •' ° � �� s, city . . r <br /> k Contractor's Name <br /> a2g C/ Lite. License #; Phone <br /> TYPE OF WORK-(Check) NEW WEi,i, /DEEPEN_/�RECONDITION.�J7----DRSTRUCTION-z—f-7�---.-._- <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT f <br /> % <br />' v Other / . . <br /> DISTANCE TO NEAREST: SEPTIC ''TANK SEWER LINES PIT PRIVY <br /> NO 1401A.5e Or SEWAGE DISPOSAL_FIELD _ CESSPOOL/SEEPAGE PIT OTHER, <br /> � <br /> ROPERTY LINE .PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _L'—Cable Tool Dia. of Well Excavation f7 : <br /> Domestic/private i Drilled. 1 Dia. of Well Casing <br /> Domestic/public f -Driven - dauge of Casing <br /> Irrigation Gravel Pack Dep,th.�of Graut 5ea1 <br /> Cathodic Protection Rotary Type,o£ Grout <br /> Disposal k Other Other Information ; <br /> —Geophysical <br /> 1 Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> ,. H.P. <br /> PUMP' REPLACEMENT: , L/ State Work Done <br /> PW REPAIR: %/ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter " Approximate Depth <br /> Describe Material and Procedure <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 "construetion. 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-puttirig- the-well in-use...." Thiel"above <br /> information is true to the•best .of my- knowledge and belief. I WILL CALL`FOR A -GROUT INSPECTION <br /> PRIOR TO GROTITING -AND A FINAL INSPECTION. <br /> SIGNED ° - 9 <br /> V TITLE' <br /> (DRAW PIAT PLAN ON REVERSE SIDE <br /> ' FOR DEPARTMENT USE ONLY <br /> PHASE I k <br /> APPLICATION ACCEPTED BY � <br /> DATE 7 -X.0 <br /> ADDITIONAL COMMENTS: <br /> ;. PHASE II GROUT INSPECTION PEAS FIN INSPECTION <br /> Ii35PECTTON 8Y . DATE INSPECTION DATE # <br /> E -H 1426 Rev. 1-74 , ��. <br />