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,('o ptv / !/'j. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOA,OFFI E USE: �f 1601 E. Hazelton Ave. , Stockton, Calif.. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � 3£/� <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 Ajja *� - h, C cJ -1-' CENSUS TRACT <br /> Owner's Name s « ,f- *fas '� -,. Phone <br /> Address City <br /> Contractor's Naell " " � License # 4&Zxj Phon4e <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN /-7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR /9-7 PUMP REPLACEMENT /? <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT 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 <br /> Cathodic Protection Rotary Type of Grout _ q. <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor l <br /> Type of Pump .,, H.P. rG-� <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: State Work Done 'Ledo e,a- U w / ,,,� -t 6 �--� <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 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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR UTING AND A FINA1, XNSYECTAON'. <br /> SIGNED.' -, RP t.... TITLE s ' . <br /> (DRAW PLOT PT-ANW ERSE SIDE <br /> FOR DJUPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION B DAT �/Y�Z_ <br /> ,.E H 1426 Rev. 1-74 <br /> 1-741ii ' <br />