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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOfi FF E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 4 Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 -Z <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued,L X 7 7- <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 bJedtfd ��«�. a w� 906 ' S'eu.l�Li A �KA CENSUS TRACT <br /> Owner's Name 4- Ye t i Phone. <br /> Address 2,70 City <br /> �. <br /> contractor's Name License # /13 7hone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/_/ RECONDITION /_/ DESTRUCTION /- <br /> TA <br /> PUMP INSLLATION PUMP REPAIR / PUMP REPLACEMENT / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES -- PIT PRIVY <br /> SEWAGE DISPOSAL FIELD ; CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOISTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS v <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 '----c e r - H.P. S r) <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /)c/ State Work,_Done ,z 6,,AdIr ga <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 'of kn <br /> q�led a g and heli <br /> e I WILL CALL FOR A GROUT INSPECTION <br /> > <br /> PRIOR TO R UTING AND A F I SPED <br /> SIGNED TITLE <br /> RAW 0 " PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYw DATE 3 'eZcj'e� 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II G OUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY ff DATE INSPECTION BY DATE <br /> 1777 _ 2M <br /> E H 1426 Rev. 1-74 <br />