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�a h� Z 41/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> b <br /> n <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 77 <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 / ✓,/k CENSUS TRACT <br /> Owner's Name Jfi.lj ,�,.,r_nG..h. -I- Phone <br /> Address 3 6 d 97 � P-r, ... City ��. <br /> Contractor's Name 1 License # iG_kZ__�hone jam=-7674 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION / / DESTRUCTION /_7 <br /> AL <br /> PUMP INSTLATION REPAIR / __ <br /> / PUMP REPLACEMENT/__ -7 <br /> PUMP <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 /> 1C Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 6 <br /> Irrigation Gravel Pack Depth of Grout Seal d <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump Y.r` H.P. <br /> �-- <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 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,�f kno ledge- nd belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G NG AND ,A FINALT IU <br /> SIGNED TITLE <br /> (D W <br /> PYO-TTLAN ON UVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I *� <br /> APPLICATION ACCEPTED BY DATE <br /> Zza <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPIEtTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - '? 7 <br /> t>/77 2M <br /> E H 1426 Rev. - 1-74 <br /> _ <br />