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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORiOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. TS= e� <br /> 7 a ot'SJQ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued S'--2,7- <br /> (Complete <br /> %-2J-(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 a the <br /> Rules ad Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT 211 <br /> Owner's Name Phone 7-3 o <br /> Address v City` c?Cil <br /> p P � <br /> Contractor's Name License ,�YJtO hone <br /> g_ T <br /> TYPE OF WORK (Check): NEW WELL /77'DEEPEN /_7 RECONDITION /_7 DESTRUCTION f7 <br /> PUMP INSTALLATION / --PUMP REPAIR /_7 PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER L;NES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD Ld CESSPOOL/SEEPAGE PIT a,-._ OTHER-- , <br /> / (PROPERTY LINE - PRIVATE DOMESTIC WELL- PUBLIC DOMESTIC WELL '==vw- _ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ` Industrial Cable Tool Dia. of Well Excavation d <br /> 4---Bomestic/private Drilled Dia. of Well Casing e9 >T-9, +` <br /> t Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout <br /> Cathodic Protection G--Rotary Type of Grout d - <br /> Disposal Other Other Information . <br /> 4-es -ZC2- <br /> Geophysical S ace Seal Installed B <br /> 9 <br /> PUMP INSTALLATION: Contractor ! L- <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: /7 State Work Done - <br /> 2MS•TRUCTION 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 t e-best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR OUTING ANE1113L ION. <br /> SIGNED TITLE I <br /> (DR&W PLOT PLAN ON REVERSE SIDE. <br /> DEPARTMENT USE ONLY <br /> PHASE I �, � ,7_ <br /> APPLICATION ACCEPTED BY DATE - -02 <br /> —�-- <br /> ADDITIONAL COMMENTS: <br /> PHASE II G I N P I IN INSPECTION <br /> INSPECTION BY A E 1 INSPECTION BrY ATE <br /> E H 1426 R v1-74. 1-74 ZM <br />