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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> U.-FOE-'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -g'I� U <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 ^ � � �' 4`"�ic .r/ j' � CENSUS TRACT <br /> I ) q3/-015-3 <br /> Owner's Name ` /j/ ..Y�t�rl�7al +/ - - Phone /,p <br /> Address �' City i <br /> Contractor's Name License Phone ?-1 <br /> ii <br /> TYPE OF WORK (Check) : NEW WELL ;!5;/ DEEPEN '/ / RECONDITION / / DESTRUCTION /'7 a <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE' TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT Oti. � OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <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 D f <br /> Cathodic Protection Rotary Type of GroutJLC <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed By: " <br /> r <br /> t PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> r <br /> PUMP REPLACEMENT: ' / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> I DES-TRUCTION OF WELL: Well Diameter Approximate Depth ' <br /> Describe Material and Procedure <br /> If I hereby agree 'to comply with all laws and regulations of the San Joaquin Local Health District i <br /> k 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-b t of my. knowledge and belief. I WILL CALL FOR A GROUT -INSPECTION <br /> PRIOR TO GROUTL400D A FI. I IO <br /> SIGNED f TITLE- <br /> D yT T PLAN 'ON REVERSE SIDE i; <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: - <br /> PHAU.II PE ION -PHASE IXIIJINAL INSPECTION <br /> INSPECTION BY TE ' f 7i INSPECTION BY DATE <br /> C1 <br /> E H 1426 Rev. 1-74 <br />