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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOJR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) ' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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 ( p h [ w CENSUS TRACT <br /> ce <br /> Owner's Name d /MQ Cori / r�yh PCL C f f p Phone <br /> Address 8' Ala, ., -.1r, City 07 G <br /> Contractor's Name ho ),I l,:nd License # 3,2l,aMftone <br /> TYPE OF WORK (Check) : NEW WELL r/ DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR ,/—/ PUMP REPLACEMENT /7 On <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK LI&L SEWER LINES Q PIT PRIVY *---- W <br /> SEWAGE DISPOSAL FIELD /Opl CESSPOOL/�gy <br /> AGE PIT OTHER— <br /> PROPERTY LINE IXPRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIQIJS <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 Rotary Type of Grout <br /> Disposal Other Other Information 4 <br /> Geophysical Surface Seal Installed By: C6tu/m,bt- <br /> PUMP INSTALLATION: Contractor /^E !' .o <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agreeto 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 DAIS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Distrit 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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUIRE Ep,,t FINU ASPECTION. <br /> SIGNED TITLE e5?�, '1 <br /> (D LOT PLAN ON REVERSE SIDE) <br /> PHASE I <br /> FOR QEPARTMENT USE ONLY <br /> -- ` <br /> APP ICATION ACCEPTED BYXLZ�� /WYDATE d1 <br /> ADDITIONAL COMMENTS: <br /> PHASE 14 GROUT INSPECTION P SE I AL INSPECTION <br /> INSPECTION BY =,�, DATE I 7 t INSPECTION BY DATE <br />` E H 1426 Rev. 1-74 ' 1/7 <br /> 7 _. 2M <br />