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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOH OFFICE USE: 1601 E.. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 - <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. --7f4l <br /> -z 3 6-f-0 _y? �LQ-J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - Date Issued ` 7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct j <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br />'r County Ordinance No. 1862 and the u' les, and Regulations of the San Joaquin Local Health District. i <br /> 3t J r v Soo` N F FELTi�P. TZ D <br /> J D)RESS/LOCATION SO' oF. F4sVo&,@ P CENSUS TRACT i <br /> Owners Name IV71W aQ,,,, Phone. L�®� <br /> Addressp E� �EL'T7Ei� p Cit i <br /> 4 y <br /> t <br /> Contractor's Name 61,9, 01,1 :�a <br /> J/,�ELL �/u.lnf' �. License �� �`��� hone 7Z69.-:322,,7 <br /> TYPE OF WORK (Check) NEW WELL`X/-- DEEPEN / / RECONDITION /_/ DESTRUCTION- /7--- <br /> PUMP <br /> ESTRUCTION /7--YPUMP INSTALLATION,'/_/ PUMPRE�E' ZR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK �/ =SEWER LINES —PIT. PRIVY �---- �3 <br /> SEWAGE DISPOSAL FIELD _�— CESSPOOL/SEEPAGE PIT OTHER 1 <br /> PROPERTY LINEPRIVA'TY— OMES.TIC WELL _. :PUBLIC DOMESTIC WELL <br /> E INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �. <br /> t . <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 /> 1 <br /> PUMP REPLACEMENT;: State Work Done 1 <br /> PUMP .REPAIR: / / State 'Work Done ; <br /> rDESTRUCTION OF WEIL': Well Diameter Approximate Depth <br /> Describe Material and Procedure F <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District {j <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of..my work ona_riew rae.11.,_I w.ill-furnish the-San` Joaquin_Local_Heal.th._District a 1 <br /> WELL DRILLERS REPOT of ani notify th=em--before--j;dt•t ng:-the:we3:l7in use. —T116—above <br /> information is true to the best of my knowledge and belief.� I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO TING AND A FINAL NS ECTION. — <br /> SIGNED TITLE ' cf <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> I PHASE I <br /> I`. APPLICATION ACCEPTED BY DATE ' w / <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> f INSPECTION BY DATE INSPECTION BY DATE -/- <br /> E H 1426 Rev- 1-74 0177 2M <br /> a <br />