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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOReOFFICE USE: 1601 E. Hazelton Ave. , '.Stockton, Calif. <br /> Telephone "(209) 466-6781 y <br /> ' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7,1 <br /> THIS PERMIT -EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1�-,),2 <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. Regulatibns. of-the San Joaquin Local Health District. <br /> JOB.ADDRESS LOCATION <br /> / _-,Z Sys' , yS T//V II. 1;9,q y7 QC A CENSUS .TRACT <br /> Owner's Name D 412AC11 Phone 2 3 Z <br />{ Address City .. <br /> M <br /> Contractor's Name e-eC Re ,4 y License #2. OEI/ Phone q -STI 7 <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN -/-7 RECONDITION /•7 DESTRUCTION /7 <br /> PUMP INSTALLATION jR/ PUMP REPAIR /-7 PUMP REPLACEMENT /7 <br /> r k _ Other <br /> DISTANCE TO NEAREST: SEPTIC TANK qo_ f SEWER�LINES~\, ��. ^_PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESS /SEEPAGE PIT OTHER <br /> e � ] <br /> PROPERTY LINE----PRIVATE -DOMESTIC•WELL - - PUBLIC DOMESTIC WELL <br /> INTENDED USE .,• f A, TYPE OF WELL . CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Took. - Dia. -of Well Excavation <br /> X.Domestic/private �"�� � Df fled Dia. of Well Casing' � <br /> Domestic/public__ Driven_. __ . . Gauge of::Gasin 3- <br /> F <br /> igaiion q Gravel Pack Dept1►�o£"Grout Seal <br /> Cathodic ProtectionT--'---Rotary Type `of Grout <br /> � - <br />� Disposal � '_ Other Other Ynformation� - <br /> Geophysical' E p� i Surface Seal Installed B <br /> /Vo Ar <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump .S'cJ�/��.�5/1QLE H.P. <br /> PUMP REPLACEMENT: ;%,I_/ State Work Done X V, �.' <br /> PUMP ,.REPAIR• -7 <br /> State Work Done f' <br /> r/ <br /> ES;TRUCTION OF WELL: Well DiameterApproximate 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 FORA GROUT INSPECTION <br /> PRIOR TO GR01=NG MD4t FINAL 'INSPECTION. <br /> t SIGNED 3 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I R DEPARTMENT USE ONLY <br /> C <br /> APPLICATION ACCEPTED B <br />'42 DATE IA <br /> ADDITIONAL COMMENTS: ` - <br /> P E II ROUT INSPECTION PHASZ III F AL INSPECTION <br /> INSPECTION BY DATE O INSPECTION- BY DATElu <br /> } <br /> 9 H 1426 Rev. i-74 ! �. sA <br />