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SAN JOAQUIN LOCAL. HEALTH DISTRICT P111 -76— <br /> 4 OFFICE USE: �� 1601 E. Hazelton Ave. , ,Stockton, Calif. �7 Ale <br /> Telephone: (209) 466-6781 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 Aereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein d scribed. This application is made in compliance with San Joaquin <br /> County Ordinance No. 186262e Rules and Regulations of the San Joaquin Local Health District. <br /> 4 fe <br /> JOB ADDRESS/LOCATION iPM A6 ,3 NSUS TRACT <br /> Owner's Name r Phone ��- Q <br /> Address ''f ,J A v7--A S A,(.g 4 ReY City <br /> Contractor's Name4'2 e—1 62 r,�a 4�f� " .1-4,c License #2-VI&43 Phone <br /> TYPE OF WORK (Check) : NEW WELL/L/" DEEPEN RECONDITION / /_7AL _/ DESTRUCTION / <br /> PUMP INSTLATION ,�­PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK ->S-6 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD >/dU CESSPOOL/SEEPAGE PIT >ISO OTHER <br /> PROPERTY LINE AT 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 'e,., 1 <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor /1�v,�c17$A4�urn�y_.[Qg2 A ar Inc Iq <br /> Type of Pum �h <br /> p ism 6 ,. :� S� 6 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 agree to comply with all `lams 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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR EPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATEy <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT -INSPECTION PHASE III/FIN INSPECTIO <br />! INSPECTION BY DATE I INSPECTION BY DATE <br /> 1777 2M <br /> E H 1426 Rev. 1-74 <br />