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SAN{JOAQUIN LOCAL HEALTH DISTRICT t <br /> FOR.:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. is <br /> Telephone: (209) 466 .678 . <br /> APPLICCATI�OR LL CONSTRUCTION OR PUMP PE T ermit No. vs—a1e-) <br /> E 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. 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 . �✓ �r�-z-�s l ev , CENSUS TRACT ' . <br /> Owner's Name C� m Phone f j ELIA <br /> Address. , <br /> City . <br /> Contractor's Name License #fid Phone <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN/? RECONDITION f-7 DESTRUCTION /-7 <br /> 4 PUMP INSTALLATION PUMP REPAIR-/� PUMP REPLACEMENT f7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL"Z.:L' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> I Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing _ 1 <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`B. : <br /> r <br /> PUMP INSTALLATION. Contractor <br /> Type of Pump H.P. S� <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP REPAIR: State Work Done <br /> 1DESTRUCTION OF WELL: . Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> landh�'I hereby $gree to comply with- all laws and regulations of the San Joaquin Local Health District tState 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 /> rWELL DRILLERS REPORT of well and notify them before putting-the--well., in.use.... The above <br /> information is true t the•best .of MY. knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO GROUTING I . <br /> SIGNED TITLE <br /> DRWW PLOT PLAN ON REVERSE SID . . � <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br />`APPLICATION ACCEPTED BY DATE <br />( ADDITIONAL COMMENTS: _Z1 <br /> PHASE II GROUT INSPECTIONPH09 j9/FjNAL INSPECTION <br />' INSPECTION BY DATE �I INSPECTION BY DATE _ <br /> 74 , <br /> E H 1426 Rev. 1-74 0//-f-cy,.a- h/75 2M 1 <br />