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j SAN,J04QU�IN LOCAL HEALTH DISTRICT <br /> FOR,OOF�FIEE USE: 1601 E: Hazelton Ave. , Stockton, Calif. <br /> • Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued )--?L- <br /> (Complete <br /> --?y_(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 _ ,, . � }��„� e„�^ 14&I jo;:2 CENSUS TRACT <br /> Owner r s Name ✓�'y► f Phone <br /> Address 12-'7 0 `Q-L tLr j IW a city - K <br /> jG a <br /> 4 � <br /> Contractori s Name cJ�p License hone <br /> jj <br /> TYPE OF WORK (Check): NEW WELL/_7 DEEPEN /_7 RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION j / PUMP REPAIR / PUMP REPLACEMENT /7 <br /> Other 17 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHERa <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: Contracto <br /> Type of Pump H.P. <br /> 1 <br /> PUMP REPLACEMENT: Ll State Work Done f 1 <br /> PUMP :REPAIR: &7 State Work Done ��/' .� %p�/G r /� Q 1&) GCAAD <br /> PES 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 thewell in use.. The above <br /> information is true to the-bes --- �my and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO OUTING D A FINAL P <br /> SIGNED TLE ' <br /> OT PLAN ON ERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III SINAL INSPECTION <br /> INSPECTION BY DATE , INSPECTION BY DATE -( - 7 <br /> yj& <br /> E H 1426 Rev. 1-74 / r` 1-74 2M ' <br />