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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7y✓ <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/LOCATIO f&R ��� S j L ?l Y CENSUS TRACT <br /> Owner's Name 49V i"/g Phane49 -� <br /> Address ��.'�`� ~ ®atm "' City <br /> Contractor's Names r •�-T`J4 �U�� License #?b',-373Phone 4tg 9%92 <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN /7 RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION L77 /7 <br /> PUMP REPAIR /-7—PUMP REPLACEMENT <br /> Other 17 <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 <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: /? State Work Done <br /> BS-TRUCTION OF WELL: Well Diameter d ' Approximate Depth <br /> Describis Materia"nd Procedure <br /> pltlL- E/ <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 Saiz 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 /> SIGNEDTITLE -k <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I j <br /> APPLICATION ACCEPTED BY fi DATE —1 ,--� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE L <br /> E H 1426 Rev. 1-74 1-74 2M <br />